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WELL/PUMP PERMIT BAN JOAQUIN COUNTY ENVIRONMENTAL HFALTN DEPARTMENT 304EWE1IERAVE3ssFL-S70CKTONCA9S202 •(209)4662120 NON-REFUNDABLE PERMIT CALL(209)953-7697 Fm IV'SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED j� JOB ADDRESS o2.3 5 N'I-z GA ,e� CD'Y21P cbt— CA / i CROSS STREET ale-4- I APN 996�//li'--�jPARC[LRDE�_ANDUSE APRICAnONr � v OMNERNAME PHONE OWNERADDRES:S / f S CRY/STATEMP ^r, CONTRACTOR Ma yP /is x ' S1_2-�/94J' �y �/� �^ �J yPxone CONTRACTOR ADDRESS � I / A�4cNSl M Y CITY/SrATE21P SL'RCOWRACTOR PHONE SUBCONTRACTOR ADDREI S_ CITYISTATEPLIP LICENSE C-57 D C-61 DD-09 D Other NUMBS EXPIRATION DATE (� GEOGR MCALINPWIMAnM: Ceordleatea X Y Township_ Range_ Sectbn__ 115 INTENDED USE DamulirfPrivrrc D lniption(Agrfmthunt 0lnduim.1 D Wooer Quality Mdntmdng Q Soil Sampling/C7vracterieskon Q C!'01R.WeerSystain IrdIR IOam Amer'. ser anm .me —1 m TvPE OF WoRR A--Wall Well O Repiscement Well D Well Alu pion/Mdifleation D That Hole D Other O Maniroring Well(,)__9ofwdls ❑Sailikeing(s) aefbon.p 0Geotahrdnl aat.mip D Well Dem"clion D OutOfSmke Well D Out-Of-S.Met Well Rrnc sal D New Pump D Pum R lacemett D Pump Repair ❑Croe.Connecdon Repair 2 WEL1.g Met er J1 DAlifog MHhod/S Mud Rotary D Air Rotary D A er ❑Gble Tout ❑Push Print D Other Proposed Well DeP\Ih _fl ExcaveuDnin diamda ❑Open&atom Cl Gravel Pack/Gavel Svc in diMrmm DConducmr i.g indiuoe / Cond''ul!nnr��Casing Depth ft Wait Casing Diameter in ThieknesaGaugoVASTM Schede EI Send ,�lasdc 0SamieM SRN DWwr Grain Seal Depth It ❑Neat Cement 04th bag/J-10 go1 wain) 0Send Chown sack mor 17 Sal Watu DR(�-IWte(2O%WI.ds) ❑Maeufacturer Sp.%%lids_% Name_ ❑Specean Rk ❑SpoesSubmitted Groot PI...ment Method O Pumped D Fr«Fdl D Other ❑AetaNaM/AecelmtpT(name) PIMMAL Installed By ❑Dollu ', ump Contactor ❑Other D Co.erett Pedestal Dimensions; Width 11 Length ft Thick is O ChristyBos D Slone Pipe PUMP ❑Submersible 0Turbine ❑Other IIP_ Pump SN fl Staling Waterl-Iyd R WELL DERTRUCTION 11 Death Bouom DOnvel Pack DUneased ❑Other Well Diameter_in Total Depth R Depth to Water R D Casing to be Perforated from_A to_ft Sating Material ❑Neal Cment(94 Ib bag13-10 galwutrr) 13 Send Cement rock coir/7gal water 0Bmwnite PERM Cl Beomnitc(20%solids) D Manufamumr Spec%solids % N.m< DSpmon File DSpas Submined Plaument Method ❑Pumped ❑Free Fall D Other grade Cl Ccurripteve to I 1 HEREBY CERTIFY THAT WI HAVE PREPARED THIS APPLICATIONAND THAT THE WORK WILL BE DONE Surface ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �I�MINIMUM 24 HOUR ADVANCE NOTICE\�REQUIRED FOR INSPECTIONS SIGNED L/f€ I P f11C�4� TITLE Ll II Ar.. diLe A UI i VI N H E EPARTMENT USE LY �7 ly. Application Accepted / Date A.Aw'.� Employee 0#73-71-541 Grout Ns to .L�'L ate7 l 13SPECIAL Weft Permit Pump Inspection By Due ❑ WAIVER RODeived Dcumcdan Inspection By Dere Ctinswetea Well Depth ft COMMENTS. n PE SC Reeeivd Cheek# Amount Data Permle IavokeN Wall IDB Cedes l"11. B u Remitted Service oeatls 2 D 0y 2Z 60 5Av 0 .39 6