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, <br />UU1-6� <br />V`(U <br />WELUPUMP PERMIT <br />SAN low, Ill CouNTY Ew womuFNT,-i. HEALTH DEPART.ENT 1868 EAST HAZrLTON AYD" - STOCCrON CA 95205 - (209) 46&3420 <br />NON-REwNDABu PEPArr <br />CALL 209 953.7697 F <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />5 U d <br />Cir 1 <br />-,�,9 r l: P' ;�, (A- <br />Joe ADDRESS <br />CRosS STREET <br />I, <br />APN J I V <br />PARCEL S. �L. UTE APPUCA/TM i <br />OWNER NAmr let" <br />`talrlp-q f <br />pp��..ee��..�� . 5(p <br />OWNER ADDRESS <br />evil <br />r#vCRIM;A <br />(31ri <br />Y_ ` a <br />(I - ® <br />CONTRACTOR `� <br />h �PII <br />(F// <br />WVL <br />' <br />CONTRACTOR ADDRESS <br />A <br />•SU6CoNTRACTOR <br />Pltpl! <br />SUBCONTRACTOR ADDRESS_ <br />e d <br />� <br />LICENSE C-57 I' C-61 <br />D-09 Other L <br />,(C],�Y-1►�$TAT}JZV <br />NUUBER ' � 157MMON DATE <br />GEOGRAPNICAL INFORMATION: Coordinates X Y Township_ Range 3ectton_ <br />INTENDED USE �, DomeSUC/Pnvate IrrigabonlAgnailti" Indusmal Wafer Quality StAtNlNxwQ Sol 5wnpang/Charactartmbw <br />Public Watar System <br />If different ft= owner <br />TYPE OF WORN New Wag Replacement Well Well Aiterabon/Modificabon Other <br />Monitoring Wells) S of weft Soil Bonng(s) sof °ofd . Geobdxrcal *orhedna <br />t�i.OfServiceffW� Out-OfS&we Wen Renewal Cross-Cormecdon Fdapair <br />Casino <br />Driling Method NJud Rotary Air Rotary Auger Cab1a Tod Ptah Point Ottner <br />Proposed Wed Depth ft Excavation in diameter Open Bottom Gravel PsddCravd See In diarndW <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Wed Casing Diameter _ in Thickl a Gaupe/ASiM Schad steel Plastic Sbw*o s Seel Other <br />Grout Seal Depot ft Neat Cement (94 lb 1>eQ/S-10 gar Waral sand Cement sack nw,1 gal water <br />Bentarvte(20%solids) t]rt>nt <br />Grout Placement Method Pumped Free Fail Otter Retardant / Aoo4araW (name) <br />,PEDESTAL lnstaded By DriOer . Pump Contractor Other 1 <br />Concrete Pedestal Dimensions: Width _ ft Length ft Thick In : Chas y Banc - Stove Pipe <br />P—U-- 1, Submersible Turbine Other HP I Pump Set_.1LS,r_ ft Standing Water Laud =44L= ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM HOUR ADVANCF� NOTICE REQUIRED F INSP7ECTIONS - �PLEASE CALL (209)2!v/4-- <br />Mi <br />7597 <br />S,GNED.�_,a=== TRLE ill( (� 1 (� t I DATE <br />m <br />q <br />V <br />- ii■■■■■■■■■■■i■■■■■■■■■r_■■nr��n■■�■r�iiiii <br />■■■■■■■■■■■■■■■■■■■■■■■■■■Ii■■iiii�! �Ilil V i ��i1r►7■■■■ <br />�"D��ARTMENT U/SE NLY <br />.• <br />0 k�icaUon Accepted By 1/-7 <br />D. Employee 10# <br />Grout 1�spe000n By Dam I 7-4AL.11 permit. <br />Pump _ �i Z7I�7 <br />Soil Bonng nsvecion By Date Cormtructed W411 Depth <br />COMMENTS <br />Codes 1; a I _a•.._ e..lr/ Rerriltted �°0i. Servid Rpt s I Imrolaa s Well IDit <br />AV] i 1)*VI Ilio a" I t. Lwk-71 �'y 1 1 w Poo 31911 <br />.�E WELL PUW PEFWr- <br />wia'.2 <br />