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r <br /> l <br /> t)r WELL/PUMP PERNUT <br />' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D"ARTMFNT 304 E WEgcg Av%31 FL-STUcwwN CA 95202-(20"4611-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FUR INSPECTIONS EXPIRES 1 YEAR FROMJDATE ISSUED <br /> Jog Aooms L 0711. o C <br /> 1 5 P-0• APN ` PARCEL h1u��[e�� � <br /> CROSSSTREET w• •?"�"`-' 1-- oLAND UX APPLICATION <br /> OWNER NAME '�; re. /-I �� �d—d:— IL Lf—C— PHONE p <br /> OWNERADDREM ZS f� e•0. C e-Ntt! I�r. CITTISTATEMIr <br /> CONTRACTOR i l.- r.k1 PHONE 6581—3AL�- /1�i np/� l <br /> CONTRAcroRADDREas - LI b-C-9-5-1 ST. CITYISTATE`Mr Sr <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CTTYISTATEIhP LA <br /> LICENSE C-57 13C-61 17 D-09 ClOther NUMBER Z4,3 0 9$ EXPIRATION DATE <br /> GLOGRATHICALINFORNtAT[ON! Coordlvetea X Y _ Tvwarhlp_ Runge_ Seetlov— <br /> 7INTE111Eu 1135 1 DamcatiTTriv m O ImgatioNAgr4mUtnal O Industrial 11 wem,Quality Monitoring w it samplinFJCherecterizar3oD <br /> I Pubbi W ate,System <br /> Ifdfft Mbamthrrcr-. <br /> Tvn OP WORK 13N—W.11 0 R.eplawncnt Well 0 Well AlteraticrJUI liattion OTut Hole 13 011102 <br /> #efb b kbFheinp �� <br /> ❑Monitoring Well{e} #otwells O svi]Bvring(a) }�r3eatxcJtnica! 3 Cp <br /> j Dewctian 13 Ose Well D ro-0W <br /> RiOD NWDI.u <br /> WELLCONFIAUCTION Q <br /> DHlling Mdhad xMu�Rotary 0 Air Rotary O Auger O Cable TOal 0 Puah Point O 011ie <br /> Proposed well 64%�1S O _ ft Eux-tion —! in diametet Cl Open BOOM ❑Gravel Pack 1 Gravel Size in dia n w <br /> O Conductor Citing in diameter f Ccadudar Caring Depth ft {n <br /> Well C.I., lNarra:ter_ih T1,sd.eWGeugdASTM Sehed 17 Steel 0 Plastic 0 St-Im Steel 0 Othet J <br /> Grout Seal Depth fl gNeat Cement(9116 bag 17-10ga1 war) O Sand CemsTd mrkmlx 17 gal water ` <br /> 0 B-"ita(20%solids) .0 Menufmturer Spec%Wids % Nam 11 Specs on Pile 0 Specs Submined <br /> Cmvt Hawasent Method Pumped OFroe Fell OOd- O Rewdmt I AbceI.Ww(eMrs) <br /> PEDESTAL IB[tatied Be 0 Driller 0 Pump Conbacte 0 Od¢r <br /> Cl Caacrets Pdnral Dtmeaelove: Width—R Lar R Thicki- ox 0 11 Chr Bstare Pipe C <br /> t PUMP 0 SuhmersLble O Turbine O Other HP PDtelp Set fl standing Weser Levc1 R <br /> WELL DESTRUCTION 0OpeA BOnam 0Gravel Peck OUrr.W OOthcr <br /> Well DiamMw_in Trial Depth R Depth to Wate R O Casing w be Pmfmted from ft to R <br /> Sealing Matvlal IT Nest Cement(94 fb bogls-foga[wafer) O Send C.mlenr__.rackmix 17 gel orator O Beatonilc PC1kU <br /> PBcntonitc(20%solids) UM.AWt(.--5 r<!s'w"h.—Y.--North)."'— - 0spce[m Hic OSpar SDbrMM"1t <br /> PLeement Method 0 Pumped 0 Free Fa13 0 Other <br /> 0 Complete with Mushroom Cap Rbotm grade 0 Complew to Existing Swf—Pad <br /> 1 HEREBY CERTIFY THAT l HAVE PREPARED THOS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM 114 COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> rr1I 1(�/ IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> [fIGNRD X Yt TTITTiIr,r ,r <br /> DATE.. 9 <br /> I <br /> qfwNr <br /> 0 <br /> 07 <br /> rY <br /> TT.Yi[Al'N[EITY"G51. �1 <br /> Apptieetion Accepted 8y-"�- (a Atee P,mplRyee IDN <br /> Gmut Inspection B .__ _ O SPeC1AL Well Permit <br /> r Pump Impaction By Date O WAwnla Received <br /> Deet—danln[pec[ian By__ Doe J Coen—td Well Depth R <br /> COMMENTSmw 99-(4y. <br /> �Ael� <br /> PE SC R--d Cheek$/ Amount YermW <br /> C.d. W. B Cuh Remitted Dale Ser". veli# IgvolTeR Well I0# <br /> EHD t]-03�06 MASTERwA71nt WZLLPEtblff c <br /> � IvlYteei <br />