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WELL/PUMP PERMIT <br /> SAN JoAQUIN Cormm ENymGNMENTAL H•DPPARmmotr 304EWEBm AvEF°FL-e OCEToNCA95202- (209)463-3420 <br /> NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS M3 S, State- Route- q4 Cru/Z@ S'ioekfal-I CA 9s7-15 <br /> CgItss mmr //ii� APN PARCELSIee L USEAIVLICAnoNN <br /> OwNea NAMe 7-Ela-V2Y1 l.OrO- PxoN¢ 858 ''�1S-Z.1-12 <br /> Ovvwrn ADDRE3s P.O. C3ox '711 - CaYISIATVLR Q�I0.$ TX hS22� <br /> Co,NTRAC Pr 0.X(Air .Services Z`'n- c . (TO�- 379(o9EL) P.O. <br /> Ls520-St/5-OZy� <br /> CONTRA=RADDRs 3'755 N. &,siness CIPst-!x-Prive_ CITY/STATEMIP TLLG5[fry A2 4S7o5 <br /> SUBCONTMCTOR AIIA PRONE <br /> SUBCONTRACLORADDRISS CTIY/STATE(LIP <br /> QaurEtQCnxC: CA Tank . 1� � b -hxthnrct4y <br /> 1101 <br /> LICENSE OC-57 OG61 OD-09 lJthu+tS+e/' 1iE01rif NsmtBER la r¢v1nrC' Ex TtONDATe <br /> GEOGRAFIDCA 111MATION: Coordinates X Y TownrMp_ Range_ Sep10n_ <br /> INIMED USE O Domestic/Private D InigaboWAgricultmel O Industrial 0 Water Quality Monitoring O Soil Sempling/ChareeterbA6on <br /> ❑Pgh.WaterOsstem Syy <br /> 1f4D'valdanma. a srmn encs me <br /> TwEOFWORK ONew Well ❑Replacement Well OWell Altemtia✓Modificetion OTen Hde XOther ELD Teskn� <br /> O MmtmW Well(s) Nofwells 0Soll Bcnng(S) NdbunnP Orm <br /> GeMech , 2a. <br /> 0 Well D etn ction 0 Out-of-Service Well O Out-a-Service Well Renewed <br /> 0 New Pump 0 PtEnp R I.meM ❑ Repen ❑CrowCormection Repair <br /> WELLCONSIAUCTION <br /> DrInIng Method 13 Mud Rotary 0Air Rotary ❑Auger OCableTrol OPush Point )(Odcr Sla ELD Iu"Plan <br /> Proposed Well Depth ft Excavation in diametn E3 Open Bottom OGmvel Pack/Gravel Size in NMneter _ <br /> O Conduelor Casing indiemeter / Conductor Casing Depth It <br /> Well Casing Diameter in T6ickncvdGauge/ASIM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 at., <br /> Groh Seal Depth ft O Nmt C=mt(9416 bag15-10gal wotor) El Sand Cement raekmer/7 gal venter <br /> 0 Bentonite(20%solids) ❑Menufectueer Spec%solids % Name 0 Specs m Fede 0 Specs Subrrdhod <br /> Grout PlacementMethod 0 Pumped 0 Free Fell 0 Other 0 Rewdmt/Acedte (name) <br /> PEDESTAL Installed ev 0 Duller O pump Ccnucc n D Odur <br /> Concrete Pedestal Dhmmlonc Width_ft Length_ft Thick in ❑Christy Box 0 Smve Pipe <br /> 2 <br /> Plsbm 0 Submersible ❑Turbine 0 Other HP Pump Set ft Standing Water Levelft <br /> I HEREBY CERTIFY THAT I 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 DI COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 6• <br /> UNI 24 HOUR ADVANCE NOTICEREQUIREED FOR INSPECTIONS S � <br /> SIGN® 41 Tme PI"Ol&J- WVf2illOAY DATe <br /> Ar <br /> A <br /> EP TMENi USE ONLY �s QQ-- <br /> Application Accepted B)'4 ©' Ama Employee IDN / <br /> Gram Inryection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection BY Date ❑ WAIVERReceived <br /> Deebuction Inspection By Date Consineted Well Depth R <br /> COMMENTS' 7 <br /> PE SC RdChee1;M(.- Annunt Pce w <br /> Cos lure B Carh Remitted Dab SesviteftDeNN IRwkeN WeI11DN <br /> Codes <br /> 5 3�5 z q o o D e <br /> ermasorass /k wer.LPuma eeamrr <br />