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1� 1 S <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304EWEDERAvx3"FL-STOCBTONCA952B2 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rqJOB AUDRLA4 � CRY/ZIP 4 — g <br /> CROSSSYREET APN I—t/ PARCEL SIZED <br /> OAMERNAMC _ PHONE <br /> OWNFRADDREN11N) 9weCRY/BrATEraP�����,/��f.�ILI//T•/����.F��j]�/ <br /> CUNTRAC IOR PPHfO/N�e/!!/t <br /> CRYISTATF/ZIP rte-J�I/[ %/ (rC 9��- 5 \ <br /> CONTRAROR ADOREDY ` - O <br /> BVKONTRACTON PHONE O <br /> SUNONTRAtI'O 99 ADMEN C IBTnTUZIP (� <br /> LICENSE C-57 C-61 OD13 Other NOMBER E%PIRATIONDATE .--3 iO r1, <br /> GRIORArNICALINFORMATION: CWMinatea % V TDwRThlp_ Range_ Satellite__ p�p <br /> INTENDEDUM <br /> O lo,gniaNAgrkulnuel ❑ nduatrial ❑WRur Quality Monitodng O Sol SunplmyCharamrimioo <br /> Sumn .w T.Nm .mIrrtry N <br /> .ntxt .mrm m.um <br /> TYPE OF WORN O New Well ❑Replacement Well ❑Well AlumtlaNModifiudon O T.Hole O Ckher <br /> O Monitoring Well(.) _ Qal.11 ❑Soil Buringla)_ moblabo," ❑(kouchtical n`eratmmNy <br /> O Well Destmetion OOw_Of-SerWre Well ❑Out-Ol-Service Well Renewal <br /> ❑New P..p ❑Pum Re ocement O Pump Repair ❑C.-Co..MLiaa it <br /> WEIA.CONYTRUC WN <br /> Drilling Method O Mud Reury, O Air Rout, ❑Auger O Cable Tool ❑Push Pain, ❑Other <br /> Proposed Wall Depth 6 F.xuvauon in diamcun Ll Open Bono. OGrAM Park/GraMl S. in diameter <br /> O Coduemr Casing in diamela ) Ceducun CNing Depth R <br /> Wall Cooing Dia nmr_in Thickou✓Gsuge/ASTM Sched ❑Smel ❑Plastic ❑Soundless SIMI OOther <br /> Grout Seal Depth R O Nut Co..,(24th hug/5-10 guI wmcr) ❑Sand Cement .tock mu/7 gal winter <br /> ❑B"wiire(20%solids) OManubamrer Spoc%selids % Name OSpecsoa Filc OSpecRSYbmltted <br /> Gnat PlRumenl Method ❑Pumped O Free Fall 0 Othrr ❑Retardant)Aeeekrawr(name) <br /> PEDESTAL Inmlkd By ❑Driller ❑Pump Conn.. ❑Other <br /> O Conerate Pedestal Dimeesiooa: Width R Icngth_R Thick in OChelsty Bax OSlat..Pipe <br /> Pune Submaluble 0Turbine ❑Other HP= Pump Set R Standing Water Levd 6 <br /> WELL DESTROClI" CI Open Bottom 0Gravel Pack ❑Unused CI Other <br /> Wall Diameter s. Total Depth A Depth in We. R O Casing to be Perforated!roto fl in R <br /> Seton.'Material O Nur Cemn,(94 lb leg/J-/Oge)wree) ❑Sand Care. amk Am l7gal weer ❑Bumniu Pellet <br /> ❑Hamnse(20Y.eolids) ❑Manuthnura Spu%solids—% Nome ❑Spatsonrik OSpines Submitted <br /> Pmemem Method ❑Pumped ❑Flat Fell Oaher <br /> Cl Co.pku with Mush,00m Cap R below grade O Complete to Existing SurRRe Pd <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 I ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M IML) 2 HO R ADVANCE NOTICE REQUIRED F R INSEE TIONS-PLEASE CALL(2099))7,--)q <br /> -) x19553--769977 <br /> 7 SH.TIED TITLE DATE ,- LTJ <br /> T 'y1 <br /> N 0 <br /> S <br /> DEPARTMENT USF. NLV <br /> -72 f7 <br /> Application Acceyud By Dau A. Empbya <br /> Grout Inspection By D.0 ❑ SPECIAL Well Permit <br /> Pumpins _IIMBytl (ktn r)ni Alga ... Con, Y'Ltl ❑ WAIVER Received <br /> Duouction Inca wrion By Dau Coadruated Wed Deptk R <br /> COMMENTS <br /> PE SC Retreated Chat Amount Data PermiU InwittN Wall IDM <br /> .Coder Int. 9 Remitte Servitt uotM <br /> a <br /> EMD 43-02-IMS MASTER WATER WELL PERMIT <br /> 12/620112 <br />