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. i WELL/PUMP PERMIT I • 1 <br /> SAN JOAQUIN COUNTY ENV IRONME'TAL HEALTH OEPARTMENr 3N WEBER AVE 3••Fl.-STOCXTON CA 95202 -1209)468-3420 <br /> NON-REFUNDABLE PERMIT '/ �CCALII..(/209)953-27�697�FoixIsSPEcno,tS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> JOBAUORESS � ^ / yV, /QLxyvZ1trz' CRY/ZIP A<M 9S2?-,D <br /> CRM STREET Nf //� �C-i/�'�c/ 'G^��/,APN !/JI_I—C (�,L_ PARCELSi2E t i <br /> 333- l oOwWNEEaR nAADMORE !PHONE_ <br /> y <br /> CITY/STATVZIP /L/pL//ate 4!9: <br /> CONTRACTOR "&R1Al,rPS GLJ� S(j_I <br /> ^ PHONE <br /> CONTRACTORADBRES\_/�J/���2/./,��/1�"" i� Crel'/STATEtZIP -J4 <br /> SUBCONTRACTOR AGZLtJS ZILL/ PHONE <br /> SUBCON RAUTOR ADDRESS_ /// /IH:Y�IC.-g /�—[._l CRY/TrATr P <br /> LICENSE -57 -6! 13D-09 []Other_ NUMBER A <br /> ERPIRrION DArE <br /> OQ <br /> GROMPHICALINMRMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE )vtx m stic1PriveH ❑IrriphortApiculWml ❑IRdoswUl ❑Water Quality Monitoring ❑Soil Sompling/Charac¢Dmtirm <br /> /❑Public W.WSy lent. <br /> Irddrenmrrom P.' -. Pew, eme --------MYt1 1mi 0t ne + r <br /> TVPEOFWORK PJew Well O Rcptacement Well ❑Well Altenlimt/Modification 0Tat H.1c 00Nhcr <br /> /❑Monitoring W'allis)__ nwAwaf 111 O Soil Boring(.)_ "Vlou"soon" OGemechuccl nvnbrr elbodnp <br /> ❑W61 Destruction Q Ow-Of-Samcc Well ❑I)ut-Ol-Ser i.e Well Renewal <br /> ew Pump 0 Ptunp Re laccromt ❑Pump Repair ❑Cmsc-Conneenon Repair <br /> WELI.CONTlRUCTION <br /> Drilling Method)Oud kwary 0 Air Rotary 0 Auger 0 Cable Tool Cl Push Poim ❑Other <br /> Proposed Well Depth_- 1_R Excavation in diameter 13 open Bottom ❑Gravel Pack/Gravel Sim in dwmew <br /> Cl Conductor C'eaing � IndiameNr / Conducmr Casm9Ds;,th R <br /> Well Casing DiameterIn ThicknesvGau&c1ASTMSchnd CL.74M OSmel Indic 11 Stainless Stat ❑Other <br /> :rout Seal Depth Il ❑Nest Cement(941h lag/.5-10gu1.,c) and Cement /0145 xockmIx/7gelwa1t <br /> ❑B.moniI.(20-A solide) ❑Manufacturer Spec e/.solids On Name__ ❑Specs on Me ❑Spew Suhmincol N <br /> Grout Placement Method mpcd ❑Free FLIT ❑Other_ ❑Reurdsot/Accelenmr(mone) 1D <br /> PEDTSTAL IBltalled By 0 Drilla ❑Pump Conned., tbther Gln.-Ti�iY�rlL_ h <br /> ❑Concrete Pedestal Diseeeulons: Width R Length R Thick in ❑Chrny Bos 0Slow Pipe <br /> PUMP ubmeruble ❑Turbine ❑Other HP Pump Sm !i Standing Water Lew] R y� <br /> WELL DETrRU IDN D Open Botuan 0 Gravel Pack D Uncescd D Other L,> <br /> Well Diameter in Total Depth B Depth to Wakr R ❑Casing l0 be Perl'onsod from_H an ft <br /> Seaiing Material 13N.t Cement(94Fit Mug/S-/0gafwnrrr) OSand Cement­,.ch mm/7 gel vnea- OBemmmik Polk. TT- <br /> ❑A.Unt a(2(PA solids) 0 Msnufamumr Spec%"ids_% Name 0 Specs on file 0 Specs SubmitInd hl <br /> Placement Method 0 Pumped 0 free Fell 0 Other_ <br /> 0 Complete with Mushroom Ca R below grade ❑Complete to Existing SurNce Pad Z <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAW'S AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MV REQUIRED LICENSE IS 7 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL n <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 7 O VANCE NOTICE REQUIRED FOR INSPECTI NS EASE CALL(209)953-7697 <br /> SlcneD1/G�n !f'�— -v �r'� DATE 2 2 C <br /> a 1 <br /> / <br /> r s <br /> -R IRE HIP <br /> A t rH E <br /> C <br /> ! a7� 3 to _ DEPARTMENT USE <br /> A ••anon nc�clgued By Dam 2- 7,o (. Ar. 2_I E,nploya,[Do <br /> rTirout IYg. By Dam /�9�e; ❑ SPECIAL Well Permit <br /> 3'�iemp lt3P19�F'Y Dam�, ❑ WAIVER Received <br /> ���q <br /> Destruction IMpedi�on/': Date Constructed WNI Depth I �^"'� R <br /> COMMENTS Afpw lo-F n-�rC([•.-n( . <br /> PE SC Received Cheekg/ Amount Date Invol.B Wan IDg <br /> Cod. Into a Ress"U., rv. <br /> 13lP6 Irti L25 L D Oo37 Ube) Dols 10 <br /> 'f3-at;- Oa•G lt 0231 COQ <br />