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WELL/PUMP PERMIT 2s 1 E <br /> SANJOAQOINCOLTTY ENVIRONMENTAL HGL7H DEPARTMENT 304E WEVERAVE3r°FL-STIMIaoN CA 95202-(209)468)420 <br /> NUN-REFUNDABLE PVERMIT CALL 209 953-7697 Fon INspec-Tons EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDitm O V W awrLIP <br /> - � a <br /> CROSS S7AFE1' 6�n�fn1/yam S�VI�� <br /> Ail �'S3-'210- 25 �1PARCErLSI2E�J�1 �¢[ rQ <br /> OWNER NAME �n 'W I✓ ` S PIIOXE ri77 J/�7 <br /> OWNER ADDREss L CQrryyl�$TwTFJLIP ,� q <br /> COXTMCTOA Wea7t /(!!! /rV O� �L-- 1-LL O�✓"+ PIIONEE,/ -3S' 2O Y <br /> CO TRARORADDRFSSB�B��1J 41� �D/.�i/k /Sy CITY/STATVZIP <br /> SuB "EACToR PHONE <br /> SUK "MCIORADORLSS �N Crry/STATVJLIP O a� <br /> LICENSE 13 C-57 E3 C-61 0D-09 �thel 1? rNUMRER73yf3f EXnMTKN DATE IT- �5 <br /> GEOGRAriux: LIKMEMATION: Cwrdewta X Y TOWnshlp R..,_ Sandwa <br /> INIENDEDUSE -411D00K311 PrivaTO D lrrigalionlAlinculnnd Dlnduwial DWdn Quality MOnimdng O Soil SaWliny{Chencredaedcm <br /> DPublic <br /> aWeser <br /> M - m a e <br /> a <br /> TYPEOFWORK ONew Well D Replacement Well D WdIAIleatioNMonifiutspn Cl Test Hole OClher <br /> wmesassns nusiberofbmiµ� rvrberabodw <br /> O Mopimdn8 Wd4e)_ ❑$oil Rodng(s) ❑Cwtchnical <br /> O Well Destruction DGuI-Os-Service Wen ❑OW-Of--Service Well Renewal <br /> OHI O pump R leeement NRiomp Repair O Crass-Corneum Schur <br /> WEILCONmeueTIOX <br /> DNlllne Method D Mud Rotary D Air Rcswr� O Auger O Gbk Tool O Push Pm ❑Other <br /> Proposed Wal Depth R Excevrlion in diamcmr DOpen Douom OGrevel Peck/Gravel Size in d'Nmder <br /> ❑CoMuctn Casing induvocta / Conductor Casing Depth ft <br /> Well Cuing DiameW_in ThickdcM/GIm jASTM ScM1ed D SWI D plratle O Swinkae Sted ❑Other <br /> Grout Seal Deplb fi ❑Neat Cemwt(94/b Aug/5-IOgal nvter) OSmd Cement xm*mu/7 gal Wath <br /> O Benlonile(20%solids) D Menuficmm Spm Yr solids_% Name 12Specs on File O Spars Submitted N <br /> Growl PHeemenl MdhwI OPumped 13F.F.11 OONer DRowdant/Accelctamr(ounc) <br /> PE MAL Installed By O Drills, 13 Pump Connector O Cnhcr <br /> ❑Concrete Pedttlas Dlmendwar Width it Lwgrh_R Thick in ❑Chdpy Box DSolve Pipe <br /> PUMP ubmemble OTUrbine DOther HP r Pump Sat 690 ft Sundieg WaRXlc+d ft r <br /> Wa„Dmnu ION ❑Once Sowm O Glavd Pack O Uncosed D Other <br /> Well Diameln_in Taal Depth ft Depth m Wascr ft O Casing ro he Pnraated Tmm_ft lo_ft Z <br /> gosling Mabadd ❑Neat Cc.[(94 lb bag 15.10ga1 wu1,,) D Sand Cement_rack miT/7 VI Water ❑Bemmmlte Pelk.D m <br /> D Bssumi(c OlPhsolid.) DMmuPocmmr Spc Yo a0ltds •h Name OSpees On RI. OSPecs$ubmined <br /> Placemeos Meshed ❑Pumped OF=Fell O Other_ <br /> O Complete with M ushroom Ca Hbelow grade ❑Complete on,Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAW%AND RULES AND REGULATIONS 1 A'SO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS SPATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS TI IAn - <br /> MINIMUM 24 HOUR ADVANCE-NOTICE. Q/,jI I RED FOR INSPECTIONS <br /> $IGXEp <br /> TITLE M. DATE <br /> Well <br /> DEPARTMENT USE N Y <br /> Application Accepted By 141 .• — Nate 4) 0 as 2-4 fo UmployclDN <br /> Grua ms0 to.By No, ❑ SPECIAL We11 Permit <br /> Pump Inspctioa By Date ❑ WAIVER Recelved <br /> Destruction ins po: w B� Dme COnsI and Well}De-pth� D <br /> COMMENTS /2 P(AOI( eAft.00 a <br /> PE Sc Ixonsuma lin ReodvedDale armed 1 Ittp Weil IDN <br /> COO. Into Resignedash BI Service R.Mqust N <br /> a{3.B OSD .SD-red _5,zDo3q -M <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 5nPD02 <br />