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WELL/PUMP PERMIT SAN JoAarN Comm EmvROteIENTAL HEALTH IMPARnwff 1888 EAST HAzELTON AvENuE - STocKroN CA 95206 - (209) 4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADORM crtr/Zm Li 4Lea. e4 95236 CRM STREET APN / 0 s -1 I0 - 3'6 PARCEL SUA •416 LANo USE AppucAT*N S OWNER NAmE L+rr!X Dertd1fro PHONE LIQ)- q-)eq OWNER ADDRESS 1061 Ho)J41% RCmISTATE2in L 61 V236 CONTRACTOR M4SC11 i J ArtjllM XA(. PHoNE i 22- ! 1l S COWRACroRADDREBB 111 A )berS iZ.l, CMISTAT&MP A&j..cj&s C, 1S3 S 7 SuncoKnUW oR PHONE SuscomTRAcroR ADDREss CmfSTATEfZN LICENSE N C-57 0 C-61 0 D -W 0 Other NurBER 169 rd 2Z ExPIRAnoN DATE y' 7 DorEsnc VVELL SAmpuNO:X General Mineral/Coliform Bacteria (4391)$' Dibromochloropropane (4392) ❑ Arsenic (4393) N TENDED USE DOM006HPrtnte ❑ IndgtBon/AgriCulhrnl 0 Industrial ❑ Water Quality Mondoring 0 SOB SemplirVCharaderimUon 0 Public Water System B dlwers km Ower: vii" systra HE Cased Name Cr Phar Isntw TYPE OP WOM New Well ❑ Replaceawt Well ❑ Wall Akra6aVModficab. ❑ Other ❑ Monitoring Wella) 0 of weft ❑ Sal Borin Ks) s a Comps 0 Geotechnical e or eaegs ❑ Out -Of -service Wei ❑ Ou44X-Service Well Renewal ❑ Crow-CmwwUon Repair Drilling Method )( Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth'&00 _n Excavation 1L , in diameter ❑ Open Bottom .4 Gravel PaddGravel Size_ in diameter 0 Conductor Cadop In diameter / Conductor Casing Depth It VWU Casing Diameter _ In ThIclumansugafASTM Schad 70 ❑ Steel �[Plaatic ❑ Stainbsa Steel ❑ Other Grout Sad Depth /410 R ❑ Neel Cement (941b beq,540 gal we" ❑ Sand Cwrwd sack mlx/7 gal water XBeMor*e (20% solids) ❑ Othar Grout PWcwwd Method KPumped 0 Free Fall ❑ Other ❑ Retardant /Accelerator (name) ISL Installed By 0 Driller Pump Contractor ❑ Other ❑ Cannot Pedestal ODbronalons: Width R Length 11 Thick in 0 Christy Box 0 Stow Pipe ❑ Submrsibla0 Turbine 0 Other HP Pump Set ft Standing Water Level tl I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Wdl�ilUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SME, '�—� Tm E 0 DATE T T -X I DEPARTMENT USE ONLY Appikstlon Accepted BY -.r—;0' Data Grout inspection By -L Das .1 Pump Inspection By f Dale r SOB Boring COMMENTS Area �i Employee IDS M ❑ SPECIAL Well Permit ❑ WAIVER Received Const uew Ws0 Depth �� R Li 8 EF04345 telne Ca�'It- 132-9X3-11 IARM EF04345 telne Ca�'It- 132-9X3-11