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WELL/PUMP PERMIT �(}� ee�ltd.' <br /> $AN JOAOSN C'0 N ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3UL gTON CA 2OY-(209)469-3420 <br /> N=E UNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDaess � —LY ��/ LAY I.�LW fZA• nTMJ7AF�\ <br /> CROSS STR¢¢T <br /> 9h t Mi IY /C!A APN� ��060 PARCELSIZE � 7 <br /> OWNERNAME JIL�1�1.1a1 R1 avy�1 �I�gy��IS,n �Yfl- PHONE /S'�/�� <br /> OWNER ADDRESS ' 1 � ✓T1•1.�i "SIF M. CTrY/STATE/ZIP1 'r,4 <br /> CONTRACTOR \Il7I ��1yyy--yyfy(��_JI LS1Ttl�n /-PHONE <br /> I <br /> CONTRACTORAUDREES I ^�.(♦=J CRY/STATE/LIP ITEM- LA <br /> cl <br /> SUBCONTRACTOR PHONE " <br /> SUBCWTRACTORADDRESS CITY/STATE/ZIP <br /> LICENSE -37 C-61 DD-09 13 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICALINFORMATION: CoordImHaI X Y TownShlp_ Range_ Seetlon <br /> INTENDED USe mmic/Privete D ImgalioNAgriculmnl ❑Indusrial ❑Wemr Quality Manimring O Soil SamplinglChamcuriution <br /> O W�liemrt'rteirrm s� m .n war .mem <br /> u CY <br /> TYPE OF WORK 'irNcw Well O Replacernmt Well D Well AltantiorJMadificabOn O Tat Hole DON. <br /> O Monitoring Wells) m�Oer4elb O Soil Bating(.)_ °101Rf1oreodap DGamachnical aumbRof bwintp C^ <br /> W❑Well Dnlmction O OuPOM1Service Well 0Out-Or--Smite Well Renewal <br /> Naw Pum O Pum R iwi ment 0 Pump Repair O Cross-Connection Repair <br /> WELLCONTIMUCTION <br /> Drilling Method Aq mud.ROOuW11 ❑Air Rotary ❑Auger 0 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depths 1 r7_ N Exe...nonID= I.diameter 0 Open Bottom )[Gravel Pack/GuvN Six in diameter <br /> OCondutwI -Casing indiametcr / Conductor�Cu�inng Deplh fl <br /> Well Codog Diameter-ILS in Thickvasa/Oaugr/ASTM Schell 6 LTJ L D SteelPlulic Sta(inlas Steel 0Othn <br /> Grout Seal Depth_;Q_fl ONal Cement(94/bbag/5-10ga1Ralrr) XO Sard Gamest a sack ads 17 gal water <br /> 0 Bentonite(20-A solids) 0 Manufacturer Spa%solid._% Name O Specs on Filc O Spas Submitted <br /> Grout Placement Method Pumped O Fra Fall ❑Other D Reudaot/Accelerator(name) <br /> PEDMAL Installed By Driller ON Contractor 0Other <br /> Gonanes Political Dimenriam: Width fl Length ft Thick in (Christy Box E Smve Pipe <br /> Pump Submemibla 0 Turbine OOther HP Pump Sct fl Standing Water Level 0 <br /> WELL DESTRUCTION 13 Open Bottom 0 Gravel Pack 0 UncaW 13 Other <br /> Wcll Dism me_n Toul Depth fl Depthto Water fl O Cuing to be Perfomled form fl in R <br /> Sealing Material 0 Nest Cement(94/b bag/5.10 gal wvter) 0 Sand Cement sock adz/]gal water 0 Bcmmmita Pellets <br /> 0 Bemmniw(20%solids) O Msnufamurer Spec%solids_% Name D Spas on Fik 0 Spas Submitted <br /> Pluement Method 0 Pumped 0 Frae Fail 0 other <br /> 0 Complete with Mushroom Cep fl below goads D Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I 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 /> MINI M 24 R URADVANCE NOTICE REQUIRED FOR INS/PPEECTI/OJNS-PLEASE CALL(209)953-7697 2 <br /> SIGNED TITLE PYfs)d�an� DATES Q1 <br /> S J A JIN CO <br /> _ PARTMENT Zll,. <br /> AppliaDon AaWtad By - — Date 16 Arae Empbyee IDN ✓I� .//� <br /> Grout Immeetio y 0 SPECIAL Well Permit /y <br /> Pump Inspection B Dau ��/�QT 0 WAIVERRecelveed�I--yam <br /> Destruction lnweetion By Dau Constructed Well DePtl[D R <br /> COMMENTS -- <br /> PE SC Renived Bee Amauet Mte Permi4 invoked We111Dp <br /> Coda Inra B ash ReMttM Service aastR <br /> 4 oa <br /> 4v M 5 00341 <br />