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98WON NVD: ll L106 '8 'APA aulil paAia3a� <br /> WELUPUfUiP PERMIT V\ <br /> SAN.IOAOUINCOUNTY EKwRONMENTALHEALTHDEPARTMENT 1968FAsrHazaLromAvl guE-aTeamT*NCA9520$-1209)4E0-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES T YEAR FRottl DATE ISSUED <br /> JOBADDREss 21360 E Walnut Dr cllymp Linden , 95236 lm <br /> CROSS H W—Y2 6 APN �� O PAR 'L SIZE9;q- �U.USF APPucAnou n $ <br /> IT <br /> OrINERNANIE F&F D Orchards rHCNE209-887— 55 IT <br /> QVINER ADORM �13 6.0E W a 1 n Ii t p r <br /> SuaooNTTtacTax elR Zoo <br /> PHONE <br /> .SUZI-NMAXTOR ADDRFS9 CI7YISTAt67jp{�/I� E 9s� <br /> LtcENSE X GS7 GBt ::D a9 Other NDraeEtt 3 7 7 9 2 3 ExelltanoN Dare 7l /1 7 <br /> G20oRAPHIcALINFOBMATION: Coordinates X Y Township_ Range Section ' <br /> INTENDED USE DomestirJPmrate If tW9a!J111Agric0lual _Industrial 7 Water Quality Monitoring _Sol;Samp9ng/Ch2=1erizAor. <br /> Public+Nater Syslem <br /> t Ifddhsxnl/mm Owren. am ma an iia or none umaer <br /> TYPE OF W2.RK _ New Nef _Replacement Weil t:Vaell AlleratloNMDdificalion Other <br /> monilefine Wells) X ormells ri Soil BariA o 'hAts T�roonn9s <br /> ngIs) t-Geotechnimt <br /> OutOfSetvice Well 'Ou&OImService LVelI Renewal ,i Cross-Connection Repair <br /> -!Now Pum Pum Replacement i.Pum Repair _Raise Well casing <br /> �ELL CONSTRUCnoN <br /> Drilling Method -Mud Rotary _ Air Rota y .:Auger _Cable Tool _Push PointijOther <br /> Proposed Wel) Depth R Excavation in diameter _Open Bottom :1 Gravel PacVGravel Size <br /> in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth R <br /> I Well Casing Diameter_in ThirknesslGaugeJASTIatSdfed Steel D Plastic Stainless Steel =Other <br /> f Grout Seal Deplh fl Q Neat Cement(941b baVS-109arwated _Sand Cement <br /> sack mixJ7 gal v2ter <br /> Benlonlle(2090 solids) '?Other <br /> Grout Placement Method :-,Pumped ;Free Fall =Other _Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Dr,Ber -Pump Conlracfar Other <br /> i _Concrete Pedestal'-Dim ensions'INidlh ft Length RThick in j.,Christy Boz Stovepipe <br /> -Z SubmerslbieLTurtrine :Other HP Pump Set' R Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE OCNE IN ACCORDANCE WffM 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAVJS <br /> �24 �CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> 9crEa TrtLE Corporate SecretgLy 5/8/17 <br /> PAY ! <br /> C <br /> REC G� M <br /> o < <br /> SAN JOA I r <br /> H <br /> FA►-Th1, N !J I <br /> i <br /> EtP RTMENT U E ONLY y///� <br /> Application Accepled By Date r� Area L41`�/` Employee II���-rl3 <br /> Grout InspecRan 8y Date �"CC��S1EEGAL Well Permit <br /> Pump Inspection By Date L D WAIVER Received <br /> Solt baring Inspecllo.l By Date �j Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check! Amount Permit/ <br /> Codes Info sh Remitted Date ServiceRequ0st9 InvoiceN well ID# <br /> / 'moi- tQa� cx1 P 034671 <br /> E <br /> EMD 17-06 <br /> 47112 R'el_rPur.�Pc7tR•Ir <br /> t,'d tL9£L9960Z oul saelpic]eoue!nund dt£:90 ZO 90 O84 <br />