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I 9 CLSP-10 �3� `V v I;elf r ti WELL/PUMP PERMIT -p SAN JOAQUIN CNPPP1(ENVIRONMENTAL ALT)I DEPARTMENT 204EWESERAVE3"'FL-STOE MCA9520= -(209)4".3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTI EXPIRES YEAR FROM DATE ISSUED au FJOBADDREM _$SAILJ.(._HA471"Aon o'ry/zIP �V l a CROSS giREET Dig 14m,+ /((/'ryI/9 .�'qPN (-rA j-�.`(j+ Qb PARCEL$ILE 3r3 of g Ca"i NAME (Jf PNONL l" OwvcRADDREss V2;7$ (IDa6f t2UAJ c rsT vz fSG� C/k S53010 CONTRACTOR ,Fut9Eo fAJ(! nPNovE 9/L'746-�p863 C�NfMCTOR AODRES< ��/ 64R. 0weiE apla "l QL•/A IGC1 CITY/STATT/ZIP L11 (.o I .SVRC0VrRA(.T0R RAM dkmcawed poi PRONE 209.7*f=Q,y3r-F" as N LNL'OM'WL'IOR ADDR[M !I('L A/, BALM 97 !i CITYISTATPJLIP A9AU7EgTA,,ft 3-5 T3if Lnna., IfG57 13 C-6! 13 D-09 13 Other NUMBER d2gr53// EXPIRATION DATE14S 4tlti / --4G I. a! 1..��RAPNiGAL INFORMATION: CgOrd{nrlrT J( Y Townehlp 0.ange_ Neelpn_ �� `� ❑ _Ini7eD USE ❑DomestielPrivele IrrigatioNAgricultunOW' l lndusuiat Oater VOolily Mnnimring ❑Soil Samre pliny/Chnclervaliun Q ~'n'D ❑Pudic Wat-System i Me um nl�y = IfdiR Mfm Ow,ur r.ppm kf TYW3P WORK ❑New Well 0 Repl cemew Well ❑Well AlterationIModification O Test Dole 12 Other NMonitoring Well(s) ( nunl rnf"e'u ❑Soil Bon s ourboofte,isi oumbaroreaio,, - BI I ❑Cemechnical O Well Drstnution 00ut-0g5ervice Well ❑Out-OFService Well Renewal ❑New Furor O Pum Re laeement 0 Pump liquor ❑Cmss-Connection Repair 1vLLCO.VRULTION Drilling Method O Mud Rotary 0 Air Rotary Auger ❑Cable Tool ❑Push Pnim 0 Other Proposed Well Dcpth15' ll E...vatiun ' in diameter ❑Open Bottom 6Govel Pack/Good Stu i to diameter ❑Conductor Casing in diartamr / Conductor Casing Depth R Wall C.Ang Diameter } in Thickness/Gauge/ASTM Sehed 4j00 ❑Stat U(Plastic Cl Sunni.S.1 ❑Other _ Croul Seal Depth OMS R a9N.tCernemt94/A#ug/5-/0gu/wwrr) ❑$and Cement ..,*.417ga1 water 31'saS III Beraontte(20%solids) OManufacmrer Spun%solids_% Nam ❑Season File ❑Spas Submitted Gout Placement Method ❑Pumped Ig Free Fall ❑Other CIR,IarduillAeeelinnson(Mone) PEDESTAL Imbued By Id Driller ❑Pump Contractor 13 Other I(COncrete Pedestal Dimensions: Width R Le.Fh_D Thick in ❑Charter IN. XrSJove Pipe PUMP ❑Submersible ❑Turbine 00ther HP__ Pump gel R Standing W'uer Level R WELL DESTRUCTION ❑Open Bonom ❑Glaoel NO 0 CncMcd ❑Other Well Dtamcter_o Total Depth R Depth m Wakr R ❑Casing to bePerforated from B to D Sealing Mabrbil 0 New Cement(94 lh b,15-10,1 &,,) ❑Smd Cement suck.1,/7 gal water O Bentonite Pellets ❑Benronite(2(ysofd.) ❑MoAfs:wrcr Spa%solids__% Nun, ❑Spec.en File ❑Spas SubminW Placement Method ❑Pumped Cl Fre,Fill ❑Other_ ❑Complete with Mushroom Cap R below grade 0 Cam lew to FARMS Sort.Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 IUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE ORA76-'T 6&a4d:Sr,5 7 DATE i � ALICE WDqER PRC Ty 25 P MW—41 4 ,2 _ Myy Wwrt"I r -- �1.�J .\��t' -T- Yu.1l w®r DEPARTMENT U$ ONVV AppliwlionAa,pted By Dan, Are. Emplit"ID# Grout Inapectiun By Dmc ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVERRecelved Deurueion Im�iection By Due Constructed Well Depth l It COMMENTS LiP/N -la rIAL%'Yda.}O SWT DAhd fbt T,T PE Sc Raelved it#/ Amounl Dare PeToW Invoice# Well ID# Cod. Info Remined ScrviceRegister,If 43 / 2 n F.HD43-02-006 iL6QOO2 MASTER WATER WELL PERMIT