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0 Well Alteration/Modification 0 Test Hole <br />t of bunnia 0 Sod Btu-trigs) <br />0 Out-Of-Service Well <br />0 Pump Repair <br />TYPE, OF WORK 0 New Well 0 Replacement Well <br />0 Monitoring Well(s) 2/ of wells <br />0 Well Destruction <br />CI New Puma Purn R nteMent <br />WELL CONSTRUCTION <br />0 Other <br />hemp Gootech meal rot <br />Out-Of-Service Well Renewal <br />Cross.CorineChOn Repair <br />4\1 <br /> <br />13 <br />.4401* <br />tr-obt <br />ivD <br />2 211 <br />NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUED <br />SAN JOAQUIN COUNTY ENVIRONMENTAL REA urn DEPARTMENT 304 E WEIDA AVE 3"Ft. - BroctrroN CA 95202 - (209)468-3420 <br />WELL / PUMP PERMIT <br />JOB ADDRESS <br />OWNER NAME ;›-iLii) 0,1:75-09 <br />CROSS STREET .APN <br /> 2tC-1- <br />OWNER ADEMESIs 2.149. <br />CONTRACTOR PSL,/,. S TAt <br />- (-1-54, <br />CONTRACTOR ADDRESS A rf <br /> <br />cir4')sTATErzip1K.; fo0 --t SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE DC-Si DC-S1 On-DO )1i0there.,.." t <br />GEOGRAPitICAL INPORRIATION: Cnordinates X <br />recesmnive — <br />CrrvIzrit ingai-Fe dig q5,: <br />PARCEL SIZE 11°3 k_LAND UM:APPLICATION Pt <br />PHONEgicA <br />CITY/STATE/ZIP <br />Ctn./STATE/ZIP <br />NE `ABER (426021:3.2 EXPIRATION DA.TE0 <br /> Township Raw Section <br />INTENDED Use iirDonrestic1Pti Yale 0 IrrigationlAgacallurai 0 frxhatriat 0 Water Quality Monitoring 0 Stitt Sampling/Characterization <br />0 Public Water System <br />If different from Chtnr <br />Drilling Method 0 Mud Rotary 0 Air Rotary El Auger 0 Cable Tool 0 Push Point 00thet <br />Proposed Well Depth If Excavation .. _ in diameter 0 Open Bottom 0 Gravel Pack t Gravel Stze in diameter <br />0 Conductor Casing in diameter I CoradueWr Casing Depth ,_ _fi <br />Well Casing Diameter in ThicknesstGauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel <br />Grout Seal Depth if 0 Neat Cement (94 lb bag /5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids _ rlit. Name 0 Specs on FIR <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other _ 0 Retardant t Accelenttor (name) I <br />PEDESTAL <br />in 0 Christy Box 0 Stove Pipe <br />Pump Set1W2_ ft Standing Water level 4g....„ <br />HERM CERTIFY THAT) HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERSCOM PEN SATION LAWS. <br />0 Other <br /> sack mix 7 p1 water <br />0 Specs Submitted <br />PUMP <br />foga lied By 0 Driller 0 Pump Coma-actor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick <br />A Submersible Tuitont C3 Other _ HP <br />LIM 24 HOU ADVANCE NOTIC a JIR <br /> Tiet.s' -L-441 /-4.2f—.: —0 <br /> <br />1 <br />M <br />SIGNED <br />FOR INSPECTIONS <br />DATE <br />ra <br />0 <br />rn <br />\f‘i <br />Application Accepted By <br /> <br />VC' <br />Croat Inspection By <br />Pump Inspection By <br />Destruction Inspwrion B <br />COMMENTS <br />.Aimpp5, <br />DEPARTMENT USE ONLY <br />Date I( bit; /) <br />Date <br />Datc__O <br /> <br />SA tt .1 TI IAA, 11 <br /> <br />ON tt, ail. <br />1-1EALT'-1 DEPARTMENT <br />Area :2-1'9 Employee ION C..) / ILI 9 99 <br />4! <br />0 SPECIAL Well Permit <br />O WAIVER Received <br />Date Constructed Well Depth ft <br />PEI' <br />Codes <br />SC <br />Info <br />Receivedj <br />By cbiCid4) ash <br />Amount <br />Remitted Date Permit/ <br />Service Rennet(' a Invoke W Well Mt <br />co gat? 1-51, -t, 0 i ii,2 /01+5-erv cto ?,a.co <br />$.114)4 WELL, PUMP PERMIT