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WELL/PUMP PERMIT <br /> SAN JOAQUIN CGRJ. Y ENVIRONMENTAL11eALn4 DEPARTMEW 701E WESER AVE 3' FL-STDEKION CA 96202-(209)""29 <br /> NON-REPUNDARLE PERMIT CALL(209)9S7-7697 FOR INSPECTIONS �EXPIRES 1 YEAR ATE ISSUED <br /> JOS ADDRESS 1O CmrAu <br /> CRQssARe[T F1 F APN 2ss-3l(a 03 rAReeLslzE'�('f�\LA�reD\�USEAPRUCLk"N <br /> OWNLR Nwwe 1/ I �,�� "ONE��1�1l�Ol�7 $flS <br /> OWNLe ADORe>3 V CRY/STATPlGP <br /> Wadk -L <br /> i COWRACroR Poore, <br /> COWDA(TDn ADDReEn C.Y(STATE/T/P <br /> $UBCOYr0.nCTOP PIIUDE <br /> Suoccn R CTORAWMM CITY/STATU21P <br /> LICENSE OC-3] OC-CI ❑D-09 )Oxh. C�21 n NUMBER E%PIMTION DATL ' <br /> CEOGRAPNICAL INtrovnlAnmO CoardlnMM x Y ToWnhip_ Rsnp_ Section_ <br /> �. INT[NOfDUSE _DomecllUPrivasteyem ❑IBiptioNAgricultural 0(ndusukl O Water Quality Monitoring 0 Soil SPDlpiing/Chnrndrna0an <br /> OPow <br /> a!.W M.,... r r..m eM un .mra PM m - <br /> TYPEOFWORK ONew Well OReplec.nrnt Well ❑Well AtlmdaNMDdifwaWn 11 Tom Note 93 other <br /> O Montt.ing Well(.) Nof welh ❑Soil Sodngls) s¢1bwNp OCxoteehncel ANladrya <br /> ❑Well Destmc6. OOm-orServioeWell 0Otl-0hScrvix Well RereWel <br /> Ncw <br /> OftempRoplacerverut O Pon,Re air O Cross-Correction ltit <br /> WELL CONSTmCTN)N <br /> Drilling Methoe O Med Rdary ❑Air fluttery ❑Aug. O Cable Tool 13 Posh Pcml ❑Other <br /> Proposed Well Depth ft Escention wdialn.. 17 op.Dml.n 0Gravei Pack/Glsvel Si. i.dierecler f , <br /> OC.,eJ.ur CAaiag mdmrncucr / C..d.wrCWng DepD ft W <br /> Well CaJog Diamem in Thikrc nJGaogdASTMSched OSNDI I7PIMtk OSuial.s Steel 13 Omer <br /> Grout Sul Depth ft O No1C¢menl(W 2A Aug/5-10gol nnuco l3Seld Cement .rxAmu/7pl win. Q <br /> O Bcnrow.(20%solids) O Mapufadurtr SFx%solids_% Name__ O Specs Dn File O Specs Submitted <br /> Grout Placement Method ❑Pumped ❑FreeFoll OOlher_ ❑Rct&n1&WAcceImwr(norc) <br /> PEDESTAL Imtalled BY 0Driller ❑Pump Contractor OOIh. <br /> ❑Concrete Pedestal Dimensions: Width_ft Lmglh_ft Thicki. O Qddy Box ❑Stove Pipe <br /> PUMP ubm.sibk ❑Turbine ❑001.1_ HP_j_ Pump Sd,�� Sending WawLvel <�D ft <br /> WELL Dr.SrgurnDN OOpu Bottom ❑Gravel Peck OUnce d 13 Other <br /> Well Diameter m TW)Depth R Depth to W.I. ft O Casing to be Perf.W form_ft to_fl <br /> Settling MMerlal O Neal Cemeur(pd/h beg/J-101./Winer) O Sand CaMnt ...A mu 17 gd anew ❑Benbmb Pelkcs <br /> O Bcownite GV1.solids) ❑Manuf=,urc Spec%solids_% Name OSpeesen Fik OSmasSubmitted <br /> Piuenlem Method O Pumped Cl P.fall O Wren_ <br /> O Compkm Pith Mushroom Cop __ft below gruk ❑Complete M Existing Smfxe Pad <br /> I HEREBY CT.ATIPE. AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCEM M SAN <br /> JOAQUIN CQUNfV ORDINA E5.STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> CURRENYAND A THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WOR CO NSATI WK <br /> a M M 24 HOUR ADV E NOTICE QUIRE D F RDF R ISP ONS <br /> SI TIn.E p2 DATE C- 13`o�i <br /> nor <br /> en <br /> r <br /> Ir- <br /> one <br /> No, <br /> DEPARTMENT II N Y I $ <br /> Application Accepmd BY Dom Am 2(f, Employee ID9 ef��`r/9� <br /> Grant Impecrion By Dam ❑ SPECIAL Well Penell <br /> pa Pump Ioapeelie,By Dam Q ❑ WAivER Received <br /> Deatm.s.inrpaedon By Don—A— C9emenew We Doplh R <br /> COMMP,NTS. __ <br /> r <br /> PE I SC Received Check./ Amount m IovlOc.N Well 1139 <br /> Ce Ma [.to Illy Cas R¢Mde\d Service Re ens <br /> 3 YU Oso s'p-Lnl 7 35 <br /> r _ <br /> non <br /> kNDI}myM MA6'IG WATFR WELL reRMli <br /> 1NUlm) <br />