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WEI_UPUMP PERMIT <br />S A'I JOADUIII COUNTY EfPARWIMFUTAL I e ALIH DEPAnTMEN1 106B EAST HAZELTOU Avcnue - SrocR Toti CA 95205 - (209) -160.3420 <br />NON-REFUNDABLE PERMIT 1250 <br />1 CALL(209) 953-7697 FOR INSPECTIONS <br />EXPIRES -1 YEAR FROti DATE ISSUED <br />JOB ADDRESS iw <br />n <br />rC <br />CIrY121P Mlq&,) �I X15 s 3 7 <br />(� <br />�_ <br />1 -0 <br />�41pq <br />CRDS$511tEET_04�/�r�t JjL%Grf< <br />Vt APN <br />RCEL/$9 IZE _ _ <br />LAND USE APPLICATION I! <br />OWNER NAME <br />PHONE <br />OWNER An DRESS <br />CITY/STATEIZIP <br />CONTRACTOR %QACWj`I, 'nZO�(IO� <br />PHOE q� <br />CONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />SUBCONTRACTOR <br />44 <br />y <br />PHONE 9D9--X13/�r <br />SUBCONTRACTOR ADDRESS /333 <br />M' y r'I� r12xwr <br />C/�IITYISTA ZIP <br />/-4101 <br />UPI IJAIJ?r (�,a�/j`"f r l q6 <br />LICENSE XC -57 C -0I .. <br />D-09 - Other <br />NURIBER. -r.�. ��0 <br />EXPIRAnotIDATE g17V1/l' <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Pacteria (4391) Dibrom Tloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/PrIvate IRigalion/Agricullur I Indusld N/at ualily Monitoring Soil Sampling/Characterization <br />Public Water System <br />If eiff• nl from ov:ner. aler5 tem lam. Conlad r lamn or Phare fLurb,:r <br />TYPE OF WORN K Ne:v Well Replacement Well J A rali odificalion )( Other 6-I fwOOJG <br />hlonitoring Well(s) It ofwel Soil Bol tg( f de "n'T` - Geoterhnial borzcrtr9s <br />Out -Of -Service Well Ou Of -Service Well Renewal Crus%-Conneclion Repair <br />New Pump -_ Pump Repla e _ mp Reuair . Raise Well Casino <br />Drilling Method X Mud Rolary Air Rolary er _. Cable Tool Push Point 011ier <br />Proposed Well Depth 2UD, A Exca fio 10" in diameter Open Bottom Gravel PacktGravel Size In diameter <br />Conducler Casing . Irl dlanleler I Conductor Casing Depth n <br />Well Casing Diameter _ in Tl}}ti��cY y/Gauge/ASTM Sched Steel Plastic Stainless Steel Other_ <br />Grout Seal Deplh V )( Neal Cement (94 Ib bag/5-10 gal w,aler) Send Cement sack mLtJJ gal water <br />Benlonile (20% so' s) Olhcr <br />Grout Placement Method X Pum Free Fall Other _ Retardant /Accelerator (name) <br />PEoeyTAL Installed By ,/7 Driller Pump Contractor Other <br />I Concrete edestal Dimensions: %1Adlh II Length N Thick in x Christy Box Stove Pipe <br />Puree -- Subn rsible Turbine Other HP Pump Sel it Standing Water Level it <br />1 HEREBY CERTIFY. HAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COLIN • ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND .TINE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT"L <br />WORKERS CO ENSATION LAWS SI yy <br />11 SUM 2;1 HOUR '\ Vk��),W REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED —BrAp. Pet A�✓t�3 TITLE DATE <br />.A <br />f pplication Accepted BV <br />Grout lnspeclion By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />N <br />0 <br />A <br />7 INN 1 .�70. <br />ION <br />SEEN <br />Application <br />• •.. <br />hI E NT U GE[�/O%/�,/��7Y 7 /!n/ `/'�' <br />•Date �0 / Area %! Employee IDII 1W <br />Date pECIAL Well Permit <br />Date WAIVER Received <br />Date Constructed Well Depth It <br />PE SC Received CheckN/ <br />Codes IL)(. B esh <br />-- -- --. _ - - ----- <br />Amount -permit/ <br />emitted Date Service Request 0 Invoice 11 Well ID# <br />O 7 V:,I=— r].a <br />Er`.D JJ -Cu tlUllla ?�,D5 _ 7083 ;.ELL II'UGP PERMIT <br />