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WELUPUMP PERMIT j SAN JOAOUrN CouNTY ENyptONMExtAL HEALTH DfPART1AE1+r 600 EAST MAIN STREET-SroactoN CA 95202-(209)"e-un NON-REFUNDABLE PE CALL 209 'ECT IONS FOR INS 'ECaNs (�E�XPIRES YEAR FROM DATE IssuEo CrTTr1T3P l�:Y`f=Joe ADDRESS �Cj � SsCROSS STREET \ �APN �t ` -3�4"-Q ] PARCEL SIZE LAND USE APPuewTtON;! liyC]- 4 I OWNER NAME `\ CTrf*TATNZm OWNER ADDRESS PHONE CONTRACTOR CRYISTATE/ZR' CONTRACTOR ADDRESS PHONE SUBCONTRACTOR ClrrlSTATE/AP SUBCONTRACTOR ADDRESS LICENSE J G-57 L C-61 ❑D-09 NUMBER An4 ExmRATmN DATE GEOORAPHlCALlNFORldA710N: Coordinate8 X Y Township_ Range Section_ INTENDED UsE omestidPri ={rrigatiorJAgricaRtural _Industrial _Water Ouafdy Monitodng D Sail Sampting/Charactenzation Publ(c Water Systeme m e ame or HCMe+ert from Owner: yI m WORK New Well O Replaceent Weg 7 Well Atteration/Modifica0on a� � i Geotechnical e of tpftV Monitoring Wel!(s) #of wells I.Sal Boring(s) out-OS-Sem Out-Ol-Service VM Renewal Ij Gross Connection Repair New pu - Pu Re ace O Pump Repair a Raise Wet!Casi W6 Lt C tT u_NrroN Qrillkng Method C Mud Rotary Air Rotary a Auger _Cable Tool Push Pont a Other ProposedWe'll Depth ft Excavation in diameter U Open Born C Gravel Pack/Gravel Size in diameter 7 Conductm Casing in diameter I Conductor Casing Depth ft Steel ❑Plastic n Stainless Steel �Other Well Casing Diameter in 7hidmesNGaugelASTM Sched a Sand Cement sack M&R gal water Grout Seat Depth ft 0 Neat Cement(941b bag15-10 gat water _ Bentonite(2096 solids) j Other Grout Placement Method Pumped 7 Free Fag ❑Other 0 Retardant 1 Accelerator(name) Installed By �_ Driller Pump Contractor Other =Concrete Pedestal Dimensions:Wdth R Length ft Thick in G Christy Box _Stove Plpe PuM XSubmersible7 Turbine ❑Other HP - m Pup Set 11 R Standing Water Level R I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY CENSE I CURRENT AND ACTIVE(WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT AM INANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT NYCOMPLIREQUIANCE(WITH ALS WORKERS COMPENSATION LAWS_ MINIMUM 24 HOUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS ` TITLE DATE / SIGNED I ENT 1VED s zoos Ullh)COUP tJMEN TAL EPAITTMENT DEPARTMENTUSEONLY �rf T Application Accepted By. Data O � (7 Employee EmPioIDX�T q l Grout Inspection By to SPECIAL Well Permit Pump Inspection Date WAIVER Received Constricted Well Depth ft Soil Boring tnspecti By Date COMMENTS �r471 � J S /' PE SIC ReceWed Ctfec Amount Date Peffniv Invoice# Well ID# Codes into ash Remitted Seriice Request# !F3 DSO wELL RUMP PERMn EHD 41-05