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.J WELL/PUMP PERMIT <br />SAiT�`. &w.1 H COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E"T MAIN STREET-SrocKmm CA 952112 _ 121191 era-IA,r <br />I YEAR <br />DRESS <br />L <br />k <br />I <br />Crtt2tP. _ 1 <br />STREET <br />yr <br />UTµ <br />/ <br />G N APN <br />PARCELS4E�AND USE APPLICATroN# — <br />NAMi <br />PHONE 3 <br />ADDRese <br />CrTY1STATE/Zm <br />LeroR <br />ICTOR ADDRESS <br />CI1Y15TAT7ef71P �! <br />rTrtAC70R <br />- -. <br />15Mr11JR <br />SURCONTRACTOR ABDitus C�ITTYISSTATRIZLP <br />LICENSEC57 L' C-61 17 p.pg ❑ Other NYarBER� n:785% F„)tAutAT10N DATE <br />v,cwwu Im L mrvHraArrorr: Uootvinates X Y Township_ Range Section <br />INTENOEOUSE meatir/Private ❑ 1Rigatlon/Agricuitural C InduSlrial ❑ Water OuallyMon ltoring a SO4SBmpling/Charaderiz2tion <br />0 Public Water System <br />It diRsrenham Owner. r mNoma""(tea Aad M y r <br />TYPE.OP WORK ><New Well a Replacement Well m Watt Attem5onmadfication ❑ Other <br />❑ Monilmin8 Well(&) _ #of wells ❑ SDUBorfng(s)aatwfts 0 Geotechnical aofbodapf <br />0 Out-Ol-ServicsWelf 0 Out-OfServics Well Renewal 0 Crosa.Connecdon Repair <br />0?51ilsw Pump 0 Pump Replacement -I Purno Reealr <br />Drllllnq Methods udftiry 0 Alr Rotary 0 Auger O Cable Tod P M)Sh Point ❑ Other <br />Proposed We <br />11 DepthT_ ' * It Excavation in diameter r Open Bum= i4ravel PacldGrauel S'" In diameter <br />C Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Oiarneter_1C_in �Tph r#nss9/GaugerASj'F4 Sched77. 0 SteG�XP13slic C Stainless Steel 0 Other <br />Grout Seal Depth "'R 0 Neat Cement (941b bagr5.10 gal waterl and Cement Z_sack mlx17 pat wager <br />1)bentonite (20% sollds) G Other <br />(3rout Placement Msthod mB Umped ❑ Free Fall 7 Ofher Retardant! Accelerator (name) <br />PED&O Installed By rillar C Pump C t acW ri Other <br />0 Concrete Pedestal Dimensions: Width Yt Length ry T Jck in 0 Christy BoX C Stove Pipe <br />PUMP ubmersibieC Turbine -1 Other HP PumpSc! R Standing Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE HONE 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLI. MCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />jYJINIPAUM 24 HOUR ADVANCE NOTICILREQUIgED FOR INSPECTIONS rs <br />SIGNEDe�i� -- TrrLk A6" DATE I —73 _as <br />�r <br />I EHD A.De <br />W=7 <br />Data 1,. <br />' <br />Area Employee ID# '/� <br />❑ -SPECIAL well Permit <br />❑ WAIVER Received <br />R <br />invoice # I W1t ID# <br />l.(l & d 73 <br />WELL MPUMP PERMrr <br />