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In4iu,k S(an t-9-4 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1858 EMT HMELTON AVENUE-STMICTON CA 95205-(209)469.3420 <br /> NON-REFUNDABLEPERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOE ADOREsa 132`1o, V C"IZIPP pMo'oem l` cA 95334 <br /> CRO95STREET ll'n1l�/LL 1 - [IVjjk <br /> 0 - �P/MCEL SQE HI//1 LAND USE MPLICATION# <br /> DINNER NAME WpD�.slde 071 Y L. I' -ZT�IO L O L.7 Fol <br /> PHONE 0116)-p 66099/-�9100 x <br /> OVINERADoatas III WD�L, 11I''�� .�IR U #•'12y50� CRYISTATEZP /�0_ l5(JIVI.CA ISL30 <br /> CONTRACTOR WOAd,Slk Pages of Nair1MT.I(Y�I FA�i6 -_P PHONE�C910469-1660 <br /> CONTRACTOR ADDRESS III W1WODI'YAV We <br /> LSo ¢�� CmISTATEMP Fo Is*m GwA 4'900,// <br /> SUBCONTRACTOR Mar-CU.I •ump -We 11 D'1111tIQ3„ k Yuba, <br /> SUBCOMRACTORADodurs 1315 BarWl (1t� � CRY/STATERIP Iu1L.lilt42cA V17) <br /> LICENSE at C57 Id C-61 U D-09JObery� NUMBER 5 1 EXP NIRA OmOT DATE01131/7-06 <br /> GEONEWHWMWFORMATION: Coordinalaex �lpp112953 Y-121.635530 Townehlp_ Renge_ SBcUon_ <br /> INTENDED USE L DamestlnPduete A Inigatlon/Agricul F Industrial :Water Quality Monitoring ':SWI SamplingrChansted2adon <br /> ❑Public Water System <br /> Ifdaamrtl enn Ow rams amen nw um <br /> TYPE OF Waix A New Well �Replacement Well Ir Well Afte etanlMotliticetion r Other <br /> u Monhoring Welts) pot Malls F,Sall Bodng(s) " bodns Li Geotechnical eetbori'. <br /> F.Out-OFSeMce Well 1,OtI14NServiee Well Renewal I;Crass-Connection Repair <br /> New Pum .1 Pump Replacement I.Pump Repoir Li Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method i Mad Rotary -:I Air Rotary I Auger 'Cable Tool I''Push Point If Other 1N(1�C11 K�TMA t�' <br /> Proposed Well Depth 100 ft EXcewtlonl ii I D <br /> —In diameter LI Open Botlom A Growl PBWGwvN S¢e � In dlemeler <br /> r,Conductor Casing ') 4'1 �lndiameter / Conductor Casing Depth T60 fl <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Schad I r� 'Wsll D SNroI ['Plastic tt Stainless Steel ,I Other <br /> N <br /> Grout Seal Depth 0 It -I Neat Cement(94 ib oag3.10 gel water) A Send Cement .3 <br /> sack MH7 gel water <br /> '',Bentaate(20eA adids) .,Other <br /> Grout Placement Method X Pumped ❑Free Fell Other L.:Retardant/Accelerator(name) <br /> PEDESTAL Installed By ADdiler R Pump Contractor ❑ Other <br /> L'Cenarete Pedestal t:Dimenelons:Width ft Lengm fl Thick in _i Christy Box F SWw Pipe <br /> PUMP YSUbmereibleC Turbine "I Other HP Pump Set B Standing Water Level it <br /> I HEREBY CERTIFY THAT 1 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. 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 LAWS. <br /> NIMUM 24 HO�VANC\E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ��� '\� TnnI V - Q DATE 1-2_R=LC <br /> AOk_Uuk;tJ It %W- <br /> LLIVE® <br /> 29 2016 <br /> MENTAL H6!jVM <br /> PA <br /> IPSERVICES <br /> RE <br /> A� <br /> � W <br /> N <br /> � T � <br /> DEPARTMENT USE ONLY �^ <br /> Application Accepted By r Date Area °7 Empbyee <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dete Cone cbd Wall Depth R <br /> COMMENTS.I.>rs'F 1 V ds. !N ltw phT�_rD rt-slu l��� , <br /> PE SC Rage vedCh Data Am_ouunt Pe�BI Invoke# WsII IDN <br /> Codas Info B a Seedbed Service Reddest 0 <br /> 1-P S zAk 8 y l6 W Z <br /> env - •1 �7 x3 <br /> EHD.S06 <br /> e]d12 wELL HUMP PERMR <br />