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loc�� IOQi � •-/ <br /> WELL/PUMP PERMIT <br /> S AN JOAQVIN COUNTY E%VIRONMENTAL I If LTII DE PA RTsi ENT 304E11'ceiRAI'E3"FL-SiOCKTOYCA95202 -(209)469.3120 <br /> NON-REFUNDABLE PERMIT CALL 209 2Y_ <br /> FOR INSPECTIONS EXPIRES I YEAR FROM DATE/7/ <br /> JOBADDRESS CII\'/ZIP aC � •�� ' <br /> CROSSSIREEi SCHttf_T� APN L�( g 19 PARCELSISE 16,5 LAKDUSEAPPFIATIOVtl <br /> O117TER NASIE .! K ro r P, <br /> /nPIIONE /� <br /> O»1FR ADDRESS `� w CIT\'/$T TFjLIP r/// �(Ay�-• /..7I�D <br /> �` f 3339 <br /> CONTRACTOR �/Y2 ` Pito% <br /> CONTRACTOR ADDAESS_ CfnYSTAT ZIP iL Uo�F ` Z/ <br /> St MWiTRACIOR _ PltON'E <br /> SVECONTRACTORADDRESS CITI'/STA,T/F/ZIP <br /> LIMSF C-57 0C-61 OD-09 0Othce_ NWIBER �`'% ExPIRAT1o.Y DATE <br /> GEOGRAPHICALINTORHATiON1 Coordinaltl X Y To»nshlp— Rang! Section_------------------t��ttt <br /> ❑T[NDEo USE ❑Domcstic/Pri%ate O lrrigation/Agriculhual O Industrial ❑Water Quality Monitoring O Soil SsmplinglC1h3nctcrizrtio1 <br /> O Public!Vater System <br /> Ir1,R.rra rr.•s .rrr: , r, aa>: _. ._' to^�-�i�,r,e aT.-I—.-t Fti.�.c, - <br /> TIPEOF 11'ORK 13 New Well ❑Replacement Well O Well AlleratiorAlodiflcation ❑Test Hole 11 Other <br /> ❑hloniloring Wells). b of»rlls ❑Soil Dmng(s) aofte .' OOvolechnieal <br /> �lYeli Destn3ction OOut-Of-Scnice Well OOut-Of-Senice Well Rae»at <br /> O New Pump O Pump R lacement O Pump Repair O Cross-Connection Rep it <br /> \WELL COSSTRUCTION <br /> Drilling hltihod ❑Mud Rotary DAir Rotary O Auger ❑Cab'eTool O Push Point OOthcr 13, <br /> Proposed Well Depth B Excasa»en _ in diameter ❑Open Dol tom ❑Oncel Pack/Grarzl Size In diameter <br /> f� <br /> OCondoctorCasing `indianxter / CorlduclorCasing Depth. A <br /> Well Casing Dianwicr je�in Thfckness'Gauge/ASTN(Schell ❑Steel ❑Plastic O Stainless SjNI ❑Other '^ <br /> Grout Seal Ikpth j fj ,ti�N,{t� 0 Neat Cement(91 lb Mg/S•20gvl w'arer) 'P(Sand Cement. /O.3 rock ntc 17 gal water t') <br /> 0 Bentonite(20Y.solids) ❑hSanufacturtT Spte 5i solids !'a Name ❑Spas on File ❑Spas Submined <br /> Grout Place men!Method Xpmpcd OFree Fall OOitsaTJ ❑Retardant/Accelerzlot(minx)_ <br /> PEDESTAL Installed By 0Driller ❑Pump Conlraetor OOther <br /> O Concrete Ptdtit l Dimensions: Width____ ft Length_A Thick—_- in O Christy Bos ❑Store Pipe <br /> PUMP 0Submersible 0Turbine ❑Other _ RP PUMPSCI---ft Standing Water Lesel _R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE!47TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH AL1, <br /> WORKERS COMPENSATION LAWS. - <br /> -Mir IM11UM11 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> $IGtiED _ TTTLF., DATE <br /> 19 12 R. S. 178 <br /> ,.. , <br /> 190........,■ <br /> 6 <br /> TvP PARca <br /> A /-- ' <br /> .DAO To PIN HTY <br /> — S4 RAEL ALtJ� 194 r ^. c AN JO O <br /> 1 rel ern 10 <br /> ,, <br /> I{FACT SILT <br /> IV <br /> 1 196 ti <br /> _ �/; DEPARTMENT U E ONLY .r/ <br /> Application Aaep(ed By_ '`--a Date �- ���— Arca --F-mplo)te IDo 4(-00099 <br /> Grout Inspalion By _ Date _ ❑ SPECIAL Well Permit <br /> Pump Inspection By ate ❑ WAIVER Received <br /> Destruction inspection B Dak Constructed Well Deplh R <br /> COMMENTS -rHtt Wa=_ 1'-et-FiiE (�ESTY'.a 1— <br /> R'r E z4S Al�w WEUI JS Ga2ane?fid - <br /> PE SC Received Check#/ Amount Date PermlV InrolaA Well Codta Inro B Remitted Senice Request A <br /> IN) <br /> [HDaYi2{•:d ---- - <br /> xf�w "ELLiL'9PEA'.IIT <br />