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W11ELLIP - MP P[ RM T <br /> SAN JOAQUIN COUNTI'ENVIRONMENTAL I-IC.4LTW <br /> T - DEPT '1868 East Hazelton Avenue-STO <br /> NON-IRE:FUNDAGlLEQC PERMIT CALL 209 963-7697 FOR INSPECTIONS IEXP11 <br /> JOB ADDRESS t Moo L �+ - W&veKy 1—A Cir,,/GIP I��/(�IpO0% <br /> a <br /> �^/Ay— �(' C 0 <br /> CROSS STREET I, .Y \ �� APN 2-4 S�I� L���-c9104 PARCELSIZE �/��✓ LAND USE APPLICATION # m <br /> cn <br /> OWNER I'1ANIE .Y��IGJ Ke 15 I I lw,0.,�e 1n " k,5,q a �_ �/� eHONE 4/�1 - �a <br /> OWNER:-IDDRESS ZMl 123 r �A�i�TVj�•��r� CITY/$TATE/GIP D�� / CIA L�3U <br /> CONTRACTOR /��Q.`` cti if brg ���( 'Tho •PHONE <br /> CONTRACTOR ADDRESS l lot A Apt r J � CITY/STATE/21P m o d PS i d 1 l � g✓�✓ 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> E <br /> /Z <br /> ip q <br /> LICENSE C-57 ❑ C-611 ❑ D-09 ❑ Other NUMBER � EXPIRATION DATE G-1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> IF different from Owner: Water System Name on ac <br /> i(PE Or WORK XNew Well ❑ Replacement Well ❑ Well Alteration/MnrlIF—" <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Bol #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-: <br /> ❑ New Pump ❑ Purnp Replacement ❑ Pum Re <br /> VVELL CONSTRUCTION <br /> Drilling Method x ud Rotary ❑ Air Rotary ❑ Auger ❑ CE <br /> Proposed Well Depth_2 P5 ft Excavatio.n in diameter <br /> ❑ Conduct Casing in diameter / C <br /> `ab'eil Casing Diameter in Thickness/Gauge/ASTM Sch <br /> Grout Seal Depthft ❑ Neat Cement(94, 1 k mix/7 gal water <br /> Xon` nice(20%solids) ❑ Other 1 <br /> Grout Placement Method umped ❑ Free Fall 0 Other <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contracto <br /> ❑ Concrete Pedestal Dimensions:Width— ove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS AP �� --WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND .,r-wUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONT —..T' COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. Ltw-,, � <br /> MINIMUM4 HOUR AD' � <br /> TA- <br /> SIGNEiD �'T $ , DATE 46 <br /> _ 1 <br />