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TP,1 o%k 5W^ I1-6-I6 ()yvn <br /> WELL/PUMP PERMIT <br /> SANJOAOMN COONW EavrRONM&Nrr .11Aw DEPART w l9 EAsr HA TONAWNUE-SIOCKTONCASS205•(209)08,U20 <br /> NON-REFUNDABLE PERMIT `' CALL 209 953-7697 FOR INSPECTIONS EXPIRES11 7 YEAR FROM DATE ISSUED <br /> JOB ADDRE39 rJ N� ,i{�'o VCnr/I>P_ �l'G(_.L-t0V1 :5�- ^y <br /> CR0;9 STREET F_eJ/O/paQ,' A'.r APN -Z10-I6PAROEL S.L,0� LAND USE APPUGAnON# <br /> OWNER NAME Sv-'ek" p( fand � 6"nr�I Lunn PHONE 53D-qD2-4Daq <br /> OWNERADDRESS ryS� OLV" �J, � CRY)STATEMP Z()Lrnt <br /> CONTRACTOR J_!!()aP/)')6Y)J 11�Q'{'PP S((/./M PHONE q31 —� 10 <br /> 2 <br /> oL/� lV/ I��X <br /> CONTRACTOR ADDRESS CIT'ISTATEZP JrTV n (/]'I- �)✓ �J <br /> Suacohnuucrm Nr. P1HONE, i�D9-�Ka zasy C <br /> SUBCON INUkCTORADDRESS I-1 r V S L4+I i-q ry CmISTATEOPJTi�A-T l'J vT A q53a-o <br /> LICENSE C-57 ' CLT I D-09 Dow NUMBER 2jjj3j�4 E% "MON DALE 9 0 I <br /> GEOGRAPMCALINFO VON: COordinateaX Y Township_ Range_ Sectlon_ <br /> INTENDED USE 'x DOmesgdPmate InigatioNAgricultural Industrial Water Quality Monitoring - Sail sampling/Chamcterimtion <br /> Public Water System <br /> nalmrenl rmm o..,,er r nem mm aewar re um <br /> TYPE OF WORK _ New Well �(„Repacement Well -.Wed AllemtloMviotllRcaOon Other <br /> Monitoring Well(;)__#of wells .Soil Bodng(s) 'awed. Geotechnical Rof tiomNe <br /> Out-Of-SaMce Well - Out-OfServira Well Renewal Cross-Connection Repair <br /> New PUMP Pum Re acernent Pum Re air Raise Well Casing <br /> WEU CON;TROCVON <br /> Drilling MethodMud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> mvel Pack/Gmwrl S¢e L 1� in dwmeter <br /> Proposed Well pth tO0 R E..tion I Z- in diameter - Open BottomkG <br /> Conductor Casing \ in diameter / Cc udor Casing Depth\ R <br /> Well Casing Diameter in Thidmess/Gauge/ASTM u Steel APlastic " Stainless Steri Other <br /> Grout Seal Dapth It Neat Cement(94111 hag5-10 gat water) Sand Cement /0.3 sack m.7 gel water <br /> Bentonite(20%sdids) Other <br /> Grout placement Method Pumped Free Fall Other -Retardant/Acceleretor(narne) <br /> E--- Insbllad By Order Pump Contractor - Other <br /> Concrete Pedestal Dlmensians:WidthR LengthRThick in Christy Boz Stove Ptpa <br /> PUMP Suhmerside Turbine Other HP '2. Pump Set 2.0 Q R Standing Water Lew9 R <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 /> 24 HOUR AD NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953- <br /> SIGNED G'`� TITLE ';NI 4— DATE A ,� <br /> pAy4fe <br /> TRTH <br /> RFCev'00 <br /> 11 DEC 0 6 2016 <br /> IT FIF <br /> TN Aq <br /> 1 <br /> AIEPAIRTMENT USE ONLY �{/, � <br /> Application AxePtetl By 1-q`13 Dala 122�,f 2 Aram Employee ID#}rg{lj v <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAVER Received <br /> Sod Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> Into <br /> PE SC Reoelved he Amount Data, PP.mriU Imolee# WNI Ium,Codes B Sash Remitted Service at# <br /> S ° 1 SQ,tt-7 6 3 1, <br /> EHOIaee WELLIPULe'PERMn <br /> N12 <br />