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0 0 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNCY ENVIRONMENTAL HEALTH DEPARTMENT 304 WEBER AVEJY°FL-SEOCKTON CA 95202 -(309)C6BdQ0 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDAPER Od �..� CITY/ZIP Y 9S2a11 '> <br /> I e <br /> CROSSSTREET IQ_APN 7119'/60-0/ PARCEL SI2E (LAND USE APPLICATION It i <br /> ONTIER NAME n CI <br /> / <br /> _ -rP•HONE ?OeI-836-/SLTI <br /> O"ERADDRESS �/-//�H TF� CITY/STATVZIP - P�! L 4 qi6:i(. <br /> CONr.,HH, (fe ^r H %��' re Lo /Tf IST AIG- PHONE 7n9-Z3//-6SIe <br /> /XK rVA y tA)tSf Ow/F�l// T CRY/SPATP/ZIP 5-r6e.f�7AAJ.CA.6,1-rW4 <br /> CONTRACE00.ADDRE/SS �,�. ...,-»�- � <br /> SUBCONTRACTOR Jyl) T II XIl Al/T�/Rl/// PHONE 21J9-h//a5- i/L a` <br /> SUBC1NTRACEORAODRE5S L'31 S W/� bA't !l Z CRY/SYATIVZIP S,�✓-">i�N/ d JS'7t -_ <br /> LICENSEE OC-61 ❑D-09 El Other NUMBCR EXPIRATION DATE O . <br /> GEOCRAPHICALINFORMATION: Coortlinvlot X Y TOwnTM1Ip 4-!5- Range_ , $eelion3_ <br /> INTENDEDUSE O Domutic/Prwele 0larigahoo/Agnculmnl ❑IndmMal Water­Q-1nitoring O Soil Sampling/ChmWtenration <br /> ❑P blie Wek Syatom e ° fI <br /> INIf IOom Omim: atw YaAm saw mw °mew °n V <br /> TVPEOPWORK ,New Well O Replacement Well ❑Well AltentioNMadifieation ❑Teel Hole ❑Other <br /> p a(hnnp NO(60nng <br /> AMPnitodng Wells) -of e'`� E3 Soil Borings) OGamchnicA <br /> ❑Well Dmimction ❑Out-0pService Well ❑Out-0f-Service Well Renewal <br /> ❑ <br /> Naw Pum D Pum R lecement ❑Pum R e ❑Cmse-Connection R a <br /> FDelfing <br /> TRUCTION <br /> hod ❑Mud Rotary ❑Air Rotary Auger O Cable Tool D Push Point ❑Other <br /> ell Depth 1215( fl Excavation in diameter OOpen Bottum OGnvel Pack/Gravel Siss in diameter <br /> OConducmr Cming indiamemr / Con'�d�,u�c^mr Casing Depth ft <br /> Well Cedng Diameter- in ThicknesNGaugalASTM ached 0 O Steel xplaatic ❑$teinlees Steel ❑Other <br /> Great Seel Depth A-/// ft XNmt Camara f94 Ib bag/5-10gal water) ❑Sad Cement .rack mu/7 gal water <br /> ❑Bemmnite(20%suits) ❑MmmfiSotmm Spec%solids_% Nome ❑Spason File ❑Spas Submitted <br /> Croat Placement Method ❑Pumped P.Fall ElOther ❑RcmNent/AcuAentm(mere) <br /> PEDMAL Iml,IIed By ADdller E3 Pump Contractor ❑Other <br /> Concrete Pedeeta1 Dimerelom: Width,5 ft Length_Sft Thiek / in OChrbty Be. Stove Pipe <br /> PUMP O Submenible 0 Tabine ❑OtherHP— Pump SoSfl Smnding Wemr Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑(Novel Peck ❑Umned O Other <br /> Well Diamemr in Total Depth fl Depth m Wamu R O Caeing m be Performd from B te fl - <br /> Seek,Mvledd ❑Need Cement(94 IS hag/5-I0gal wale,) ❑Sad Coment sack mtr 17 gel water ❑Bentonite Pollee; <br /> ❑Bmmnim(200A solids) ❑M.mRR mmr Spec%solids_% Name ❑Spaa on File ❑Spas Submiud <br /> Plaemenl Method ❑Pumpd ❑Fra Fell ❑Other <br /> O Camplae with Muehroom Cep fl below grade 0 Complete m Existing Sortie.Pd <br /> 1 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, 1 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 /> INIM UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �',, <br /> $IGNED TITLE <ACCl'1Z,f S'/ DATE T::/n <br /> i <br /> ' % .SRP. _\ _-� ::'1"��G=\:\\�P �� ,•� -� J � <br /> Or I <br /> Ts�p <br /> DEPARTMENT E LY P/61 Emp'f E.f.<� _ <br /> APPlicadon Accept r Date Mm <br /> gr <br /> Grout lowerti Y Co. ❑ SPECIAL Well Permit <br /> Pump lmpecti By Date ❑ WAIVERReceived <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS S 16 c , <br /> 2 0 I -r B /o <br /> )LS 0 <br /> PE et Raelvd Chet A at Dvle Pe Req Involtt8 WBII IDp <br /> Cotler tato B Cvsh Remitted Service Re ueatp <br /> Z ! 3 <br /> MMTER WATER WELL PERMIT <br /> ENOO-0i{OM1 <br /> ]/1NW] <br />