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LHS'ON Wd6ti:Z[ ti[H '9Z'gad 11-111 paAiaDad <br />WELL/PUMP PERMIT <br />SIM JMMXM CouNIY 9ftft0WWMTAL HEALTH DD AR7IIMT <br />1868 EAST HAZELTOM AVIVNM - $toexYow CA 115M - (A9) IaS- n <br />NON-REFUNDABLE PERMIT CALL 208 8S3-7687 FOR IN9PEcnolsis EXPIRES 1 YEAR FRom DATE tssueo <br />J. A.. I / w L � Wy- <br />1 <br />CRasaSTREET APIN/�,� <br />ARM 592 —LAM UsE,Aw <br />D <br />OWNER NAME IRO 11 <br />nr^crT" <br />W <br />OlrumeAooaeas WI/ <br />O IaTY,STATCONTRACTOR <br />/ 1� <br />=bC4 <br />Auoiroa V <br />9CONTRACTOR <br />SCrrws ATEIiSP <br />SUBCONTRACTOR .._ <br />PHONE <br />SUacownACToR ADDResa �- <br />CMISTATErMP <br />Lf mwe ) G-57 ❑ C"AT 0 D-09 _! Other <br />MmmeER E)MPATkw DATE <br />GEomtAPrcALIwcwmATm: Coordlns6sex Y <br />TOwn9Np_ Rmrrge Section_ <br />)NTENIpW Ue® EI Domestfc0rivate rrtge9orVAgridalhe7d U Indesbtel <br />a Wat rQuAlb' mmftdw r Sa Sem <br />n Pudic Wafer System <br />If dlllerart MOT Ower` <br />,e <br />TY" OF WORK P New Werl _ U Replace nerd Well C Wel AllerstlwrModlAcalion <br />,-J Other_ <br />I <br />Li MoNtoMg Yvell(s)� s of welb I.. Sea Bodrvo) <br />=o1Do""� I.l Gaotedxlkel of <br />Li Out-Of-SeMce Wap (� Oul-06SerNee <br />Well Renewal .:I Cm"-Connectkm Repair <br />]l, <br />11 New Pump U Pump Beplecenfern L Pump Repair <br />.J ReNee WaR Casing <br />Drilling Method r%Mud RotaryI I Air Rotary ri Auger n Cable Tool I Push Point f Other <br />Proposed Well Depth_ _ 500 It E."Moi , Z, In dtameter a Open Bottom I,I Gravel PockJGmwl Size ,,_„ ki d"te'r <br />❑ Conductorfeeing In diameter / Conductor Casing Depth R <br />Well Casing Diameter (J In Thldrfleae/Gauge/ASTM Schell l I SI ".I )Olwtia IJ Steinlesa Slael LI Other <br />Grout Seal Depth It I1 Neat Cement (94 Is baq'5-+0 ger wefeh k Ssnd Cem.f (0, 3 __ _sack mbrfr gel wateT <br />n Benferwite (20% solidi) U Other <br />Grout Pfaeer amt MOM64 C.1 Pumped 1.1 Free Fall 0 Ottw 0 Relardsnt / Acr *rHcw (n ff ) <br />YEpFBTAL InstMlled By I, Dollar 1.1 Pump Conlrecfor ❑ Other <br />,i Concrete Pedestal .1DUTrenslon8_ Wldlh n Length it Thkk _ in J Chrtaty Boot u Stove Pipe <br />i.i Submersibleu Turbine LJ Other. HP Pump $et R Standing Water Level n <br />1 HEREBY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT ANDA Ve WITN THE CALIFORNIA CONTRACTORS STATE LICEf$$ BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WOAKERS (01N TION LAWS <br />MI O R %��UII{ED FOkIINySoPECTIO S PLEASE CALL (208) 95 7687 (L, <br />SfaMM pU��% TITUE V."C.''/y ��iS'1 DA1e 0.4 rL <br />DEPARTMENT USE ONLY <br />Appllcafbn Accepted Gy ! <br />Date LI L'A1 1 Arrsto Iii l EmpbyeeIDS E�ty� S <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Punp Irmpecuon By Data 11 WAIVER Received <br />$oil Boring Inspection By Dole Constructed Well Depth it <br />COMMENTS <br />amo 43-M will Ater PQRraT <br />utarrs <br />L /9 `HSVd 00=00 TTOZ`TO`112r <br />