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ow <br />SAN JOAQUIN COUNTY EwRoNw <br />NON-REFUNDABLE PERMrr <br />Joe Amwst s3 (P 5 b <br />A ISM <br />OWNER NAVE <br />OWNER ADDRESS <br />WELUPUMP PERMIT <br />HEALTN DrPARTYENT 1868 EAst HAZMToN AYMM - STOO roN CA 95205 - (20.9) 4683420 <br />CALL 209 953-7697 FOR INSPEC I(M . EXPfRES 1 YEAR FROM DATE 135MD <br />-7 <br />APN V !� 9ARCM S. Ti -1 AOPIrCATiON <br />lel l3-7 t ! -Ln L <br />COMRACTOR AD . I V. V- V —F <br />SUBCONTRACTOR <br />fv <br />SUBCONTRACTOR ADORESBIQ <br />` <br />LKFJ+5E 0,57 C-61 D-09 Ojj <br />GEOGRAPNKAL INP09kATION: Ceordirud" X Y, <br />Num em L• 157wAT10N DATVr -' f Ly %--% <br />Cv <br />Tewnsnlp— RwWSecilon_ '*'l <br />INTENDED USE I/ Dourest WPrfVdte Img8WMiAgr1cx=;ral InduStrlal Water Quality MOnllumg Soil SernpWlg/CharacterizaCOn <br />Public Water System <br />If e8lerem tram ONTmer <br />TYPE OF WORK New Well Repiacernent Well We(, APterzSon/Mc ii1ic;&Wn OU'Ar <br />MonitoringWed(s) Sof weft SoilBonng(s) AofbW" .Geotedrocal 9 fb inp <br />!\ <br />Out -Or cin Wf� OUt-OfService Well ReneWW C+esc-Carv>edfon pew <br />0191 <br />r� <br />! <br />New Pum ✓ R ent Pump Repaw Rw" Well Casingj <br />fe <br />xatL �NsrxucnoN <br />Drilling Mettrod Mud Rotary Air Rotary Auger Calve Tool Push Poch ODler <br />�' <br />Proposed Well Depth R E=avabon in diameter Open Bottom Gravel PadJGn" Size in diameter <br />Conductor Cas ng in diameter / Conductor Casing Depth tt <br />Well Casing DiameW in Thidvtess/Gauge/ASTM Schad Stad P(istic Stairtlase Steel Other <br />_ <br />Grout Seal Depth ft Neat Cement (941b beg,5-10 94,/ water) Sand Cement sack m*17 gal water <br />Bentonite (20% solids) OCmr <br />Grout Placement MedTod Pumped Free Fail Other Retardant / Aeoelensor (name) <br />PE lrmbB d By Driller Pump Contractor Other <br />'Concrete Pedestal Dimens►wfs: Width _ ft Length ft Thick M : Christy Bo: '.Stipw Frye <br />PuuO Submersible Turbine other HP 6 d Pump Sates ft standing Water Level f � ft � <br />HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WIUL BE DME IN ACCORDANCE WITH SAN <br />�r� <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />cU VWEWI E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM 04 COMPLIANCE WITH ALL <br />W RS PENSATION L_ <br />IMUM 24 HO CEN ICE REQUIRE FOR��(pVSPECC„TIONS - PL AE CALL (209) 91P3 -7q97 <br />r <br />Tm(p �0 <br />E Y�/� P m �� /� . DATE <br />0 <br />t •' - ill y. /I( � <br />Anm4��11 <br />E ... <br />ENC.1im WELL PJW PERNIT <br />4,30,* <br />3 2d"l <br />