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1' 3 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUIaY ENVIRONMENTAL HEALTH DEPARTMENT 301E Weems AVE 3"FL-STUCKTOn CA 95202 -(309)46&3120 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR PROM DATE ISSUED <br /> S n <br /> JOBADDRPSS _ Y CmIZ11 <br /> CR098 STRLET(Gw.OL O APN.OI 3ZO—©&AxCELSUZ LAND UMAMLICATIOND�s g <br /> ` lN? <br /> owner HANE .Qi1.� SL hl molLS' 731-)A P//xonE� p <br /> OWNER ADDRP88 yleG�/ L�� �I 1ON�� �_ Cf1V/h7ATPlLIP O�'� +C' <br /> CDeDRAGIOR 1 r1 a�1lL f )�.^�l �(Pi117 PHONE <br /> I4 ' <br /> COHTMLTOR ADORRv A-1Ee^S F[f. cM/srnrEnar <br /> SUBCONI'RALTOR PHONE <br /> SUBCOKEnu, P RADDRESS CfIY/STATil9LI�cP� /.� <br /> Lu:eNsE C-57 Cl C-61 Cl D-09 D OtherNUMBER G — E%nRATNUN DATE -?' <br /> GEOGRAPHICALINFORAIATION: Coordinate, X Y Township_ Range_ Session_ fT� <br /> INTENDED Use DomertirfNri .tc Cl ImgotioNAgrieultunl ❑Industrial ❑Waw QWity Monitoring Cl Soil Sompling&1noncteriation `\ <br /> ❑Public Water S tem <br /> Nl;rnor 6wn1 „inofseaS,sassiNswe .un w um <br /> TYNE OF WORK ew Well ❑Replacement Well ❑Well AltentioNModifiution C3 Met <br /> ❑Monitoring Well(a) M of wells 13 Soil Borings) a ellednn ❑GenteeMieal 0 of terin, <br /> ❑WtOf-Service Well Cl Out-Of-Service Well Renewal ❑CrouLonnoctien Repair <br /> 13 New Purip, O Prunp Replacoeiew O Pump Repair <br /> WELLCONSTRUCIION <br /> Drllling Method )<Mud Rotary O Air Rotary ❑Auger O Cable Tool O Push Point <br /> �/ ❑Od. <br /> Proposed Well Dept2(, �^ fl Exwvarion�in diameter OOp.Bottom ACQ.vlPack/Cmvel Sim in diarrMa <br /> ❑Conductor ng indiemaa / CorAucWt Gating Dept R <br /> Well Casing Diometer in Mwknesa/Oeuge/ASTM Sched� 13 Steel lino, ❑Stainless Steel ❑Ota <br /> Grout Sed Depth It ❑Neat Cement(91lb bog1J-l0gal carer) O Send Cement sad mix/7 gal water <br /> tF61entonite(20%solids) ❑Maufaaum Spa%solids % Name ❑Spa,on File ❑Specs Submitted <br /> Grout Plaaewet Method ❑Pumped D Free Fall ❑Other ❑Retadent/Accelerator(name) <br /> PEOTsrAL InstallM By ODriller Pump Contractor O Other <br /> O Ceeereh Pedestal Dlexnsiona Whith ft Length ftThick in ❑Ckrbay Boa ❑Stove Pipe <br /> PUMP ❑Submasibk CI Turbine ❑OtherHP Pump Ser ft Slanding WaterLevel ft <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 13 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /MINIMUM 21 HOUR ADVANCE NOTICE REQul ED FOR INSPECTIONS <br /> SIGNED I/�`f . /�CCl21 rf TmE P,t I�QN DAIS <br /> P <br /> 4 <br /> E <br /> --- <br /> J(A <br /> O AIUh <br /> 7y <br /> 3rA AkE <br /> DEPARTMENT USE ONLY I/Cq <br /> Application Awepted By 4 Y 3 Area EmployalDM <br /> Grout Inspection By ,l�l � Date ❑ SPECIAL Well Permit <br /> Pump Inspection By I%M ❑ WAIVER Received <br /> Conamseted Wall Depth ft <br /> COMMENTS <br /> PL SC Reedvtl Anruot Mh hrmlU law, With IDM <br /> Cela Info B Rendned 9arvin rrtM <br /> 436 �Pr IS 3 n s, b w�a <br />