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WELL I PUMP PERMIT <br /> SAN JOAQ004 COUNTY F.NVLAONMZNTAL HEAt.Ttl Dt'xAxXrstrNr 600 CA wMAIN Stv"T-STOCLTON CA 95202-(209)46&3I28 <br /> NON-Riw-UNDADtxPk;RMIT CALL 24I9 Lj}3=;(t}7}I}hi7VgPIf"P'il3\S" EXPIRES lY EAR FROM DATE ISSUED <br /> JmAuuxxas CITY <br /> �IZ�I^r� s' <br /> Cttatvs S'TRKXT API+I (Iv PwecsL Size <br /> OwNEKNAmx PRON>� ! <br /> OWN""DI Cm6rA'rF4ZrP <br /> R \ <br /> CorrlltAcrax Px C <br /> CarrrxAcrtxt Almxtss r CtnlSrArr12�SUBCONIMACT01t HONE <br /> I <br /> SUACON'IRAC'TOR ADDRES1 CirY/STAmZip <br /> l <br /> LaCXNSE 0C-57 ❑C-nil 13D-09 Otha — Nrr7mmER Wm7noNDAn <br /> GEOCttAPtlle"IN FORMATION: CAardilllltea Y. Y TowOsi;tip Ilaugo Section <br /> INTENDED UsE . DOntestic/PIIvau., ❑1Mgat1CrdAgric1dt1[al Q Industrial 0 Water Quality Modtoutg ❑SW Samplmglcb..teriwim <br /> Public Water System <br /> Udf—af..D-: Wale Syiect Nowv ConWciNsaenrPt d- <br /> '1'vvra OF W0" a New Well M Replacentcnt Well 0 Wetl fidwration(Modificatien ❑Trat I-Iota ❑Oohs <br /> ❑maaii'16n s 6 Soil Dori uem6cr orwcSa awaaca[6odngs aum4�rutbalw <br /> E Well() ng(s) A Cnateciuticsl � <br /> El Well Destruuton ©Out-Of-Service Wctt ❑Out4X-Service Well Renewal <br /> ew Purup ❑Punip Replaceniani 0 PWP ge air ❑Crnss-Connection Repwr <br /> W RLL CONaTRtnCTr <br /> Dr11Wtg Me1Md a Mud Rotary.: ._1.Air Rotary 13 Auer __._[I.Cabla Tool..,. ❑Push PvintRtiO 6[her _ ----- <br /> Prvpesed Well Depth R Excavation M diameter ES Open Bottom d Gravel Park/Gravel Size in diameter <br /> 0 Caidactor Casing in diameter I Conductor Castag Depth fl <br /> W49 Calatrg DuuDuu in TWof;D. daauye/ASCM Sched O Stcel ❑Plastic 13 Stainless Steel ©Oilier ; <br /> Crowd Sad Depth ft ❑Nr t Cement 194 J6 bag!5-10 gp!wale) 13 Sand Cement suet min 17 gal water <br /> U Benlomte(200/4solids) ❑Manufazu=t Spec%solids % Name 13 Spas at File O Spurs Subnuuted <br /> Grout M.witteoi Method 13 Pumped ©Free Fell 0 Other C)Relarddw/AcodamWr(name) <br /> YEDPSTAL Indalled IIY Q Driller 0 Pump Contractor f3 Other <br /> ;. 13 Coucrde Pedestal Dbutcttsivi& Width It Length A Thick irr 17 Chrldy liar ❑Stove Pipe <br /> 1'uMr Sulntnnyble ❑Turbine 13 Other IIP Pump Set A Sutadtrg Water Level ft <br /> I WELL DESTRUC ION 13 Open Bottom P Gavel Pact: 13 Uneased 11 Other [� <br /> Well Dirmwier in Total Depth fl Depth W Wa cr ft Q Ces ng to he Perforatedfrom !t to it `C <br /> SeaDog Material-• ❑Neat Cement 1941b bug!5-14Su11anterJ ❑Sand Cernent ruck ma 17 gal water ❑Rentanite Pellets <br /> U D<tntanitc(20%solids) ❑Manaraettuec Spec h solids % Name ❑Specs at File ❑Specs Submitted <br /> Placermulf Me[Itud 0 Ptaruped 0 Pxee bail C7 Oth r - <br /> ❑Complcuc with Muslvomtt Cap A below grade l7 Complete to F.Idstmg Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARE:➢'THIS APPLICATION AND THAT THE WOIWI.WILL BE DONE RI ACCORDANCE WITH SAN <br />` JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERIKVY TRAT MY RI~QUfRED LICK4SE:IS <br /> CURRENT AND ACTIVE WITH THE CALWO RACYO STATE LICENSE OOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSCOMPENSA WI <br /> fl�iCti r-ltFf)�[' - ti "I rOiC' [l1ftC1J} F ' IGCTItI iS <br /> f NRINED 7r DATH <br /> -44 <br /> PEC MENT <br /> RK V ED <br /> f AUG 12 '2000 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> !' PARTMA7YT <br /> Applicatian Acceptc Date Area Employee 1D# C(� <br /> Caws Inspcctian By ate 13 SPECIAL Well Permit <br /> Puattp]mpeclitzt B _ Date 1� 17 WAIVER Received <br /> Dejn-tiailnspec' By Date Coadructed Well Depgl R <br /> COMMENTS D <br /> PE SC Rteetved AtmonO <br /> (4o s Into II Cash eutitlYd Dale Service Re uert# luvoke# Well R1# <br /> 5'D 3S6 U 6 1 <br /> EHD 43-02-006 WED - WeII Permit ru4 De:iwatiat.tlac <br /> 911 1/2667 <br />