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GEOGRAPHICAL INFORAtArake Coordinates X _, Township Ranee„ Section <br />VIENDED USE DomesItoPrwate lrr,OaflonAW1Cullt,fal InduseMI Wants' Duality Monitoring . Soil Samptingitharactenatitort— <br /> <br />PUDIJC MAO' SySIEST1 lowort3 from Own!, 7755--SysTyr Name <br /> <br />ti.,NtwY Natrz or «'fmne Nxetwr <br />JOS. ADDRESS <br />CRoas S t Reel <br />OWNER NAME <br />:CONTRACTOR <br />1CONTRACTO4t ADDRESS <br />OWNER ADDRESS <br />-19114' <br />Codes <br />. WELL/PUMP PERMIT <br />SAN JOAQUIN DOUNTT ENVIRONSIENTAL HEIU.111 DEPARTMEN" SOO EAST MAIN STREET • STOCKTON CA 95202 - (209} 468-3420 <br />NON-REFUNDABLE PERMIT 9$3-$S7 FOR IctoNs EXPIRES 1 YEAR FROM DATE ISSUED <br />0 <br />(7 C 2 I c C Mao IL "IL <br />PARCEL SIZE _fLLAso USE APPLICATOR 0 _.......... , . 0 ,., <br />PHONE <br />Crn(S TATE/13P I VcAG.'1_ CA- i:/r ) __)) La <br />PNO E (.62.:i((2. <br />CirwSTATEGIF <br /> <br /> PRONE <br />CITWSTATE/7..iN _ ---- <br />NANNEEERCI .7'7)7)9 E,SPNEAVOS4 DATE <br />SUSCONTRAcToR ADDRESS <br />UDENSE C-57 C-61 D-439 <br /> <br />TyPt pc WORK ' New Well Replacement Wee . Well Alterationek011ication - Other <br /> <br />a Of bOrins-s it <br />Monitoring Well(s) it of weIls Soil Boring(s) Geotechniati <br />Qui-Ot-Serrice Wet , Out- Service Well Renewal Cress-Connection Renoir <br /> „ New Rump • Pump Replawnent Pump Repair <br />:WeLL. ODN STRuC 'DON <br />I C/Idling Me.[NDO Mud Rotary Air Rotary Auger Cable Tool • Push Point .. Other <br />PreposeO Won :lepth .., It Excavanon in oliamer Open Bottom • Gtaidel PearGreyek Size in diameter <br />Conductor <br />- <br />ConductoT Casing in diameter 1 Conductor Casing Depth It <br />Well Casing aiarneter it ThiatnesstGauge(ASTM Schee . Steel Plastic Stainless Steel OtNer . <br />• , <br />Grout Seal Depth _ „ ._ it - Neat Cement 1'94 lb bary5- Y o gal water) Sand Cement sack 1x1 11 ahAoler <br />I Bentonite (26% $,aids) - Other <br />Grout Placement Method Pamped Flee Fall Other ,.. _ <br />I PEDESTAL Instated By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width -ft Length ft TNcic . COristy Box _ Ste . - I , , <br />Submersieterurzir,e - Other , „„___ HP Ill__ Pump Set„1&;1_1--/I ., ft Standirip ,.vatei- -cevri, 111.„..„„. f, EAT <br />l HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TliE WORK WILL BE DONE iN ACCOFiLIANCE WITH SAN .",----- <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS,. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS (N, <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, ..., <br />SIGNEC <br />CN,) <br />WI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />I TITLE DATE <br />" 7 <br />A,P•Pbc41001 AcveDtett <br />Grout inspection <br />Purno inspection It, Date <br />S.)0 Ronnq Inst,\-,/,tnon <br />OW; • s • <br /> <br />Date construe,ted Well Depth <br />/4"':100 tria-tit r e <br /> <br />Rece,voci C API auntDate Permit/ invote <br />ei Zee% Remitted R.tWellt <br />Well lD <br />4; 3" <br />ri Employee IDe _ <br />SP COM- e I Permit <br />WAIVER Received <br />EHD altA <br />MAPS <br /> <br />WiLl./RAP FTRARFF <br />