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10qT) Co/ cs_ts <br /> WELL/PUMP PERMIT G 6 en- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER AVE 3"FL-STOCI(TON CA 95202 -(209)468-3120 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> H <br /> Joe ADDRN <br /> 833 �/y?F'l� Y � , Oat .Em.f CItYa1P Gr12Ql y <br /> /y /y� I �yn e <br /> CROSS SrHxgTr APN fN3'I(Rl"�y PARCEL SIZEy3L—WND USE APPLIG1lONq <br /> O"ERNAME C17e�I J/Si /IqY W2,LQ // PHONELtJrf-33y-3Y/dt/ <br /> O"ERADDRESS /Io Yd N /-IIT 96a A�' CITY/STATgaS-h � CLQ <br /> 1P CCq-vIet <br /> CONIRALTOIt Alen aAq//EVJ(pyl\ 'e.r/yx OL PHONE ZO1!-SO-32"t <br /> CONTRACTOR"DRESS 9pd 1/14 VS/YIG Wily CM/STATFIZIP 4W,'. c-A9--a <br /> SUBCONTRACTOR SaaTt{ PHONE <br /> SUBL'ONIRAROR ADD11L6 CITY/STAA.TF21P <br /> LICENsE JCC-57 0C-61 OD-09 ❑Otho NUMBER - IN ExmHADoNDATE Q <br /> GEOGRAPHICALINPORMATION: C000HOSM E Y Tow"hip_ Range_ Seado <br /> INTENDED us L O Domadc/Privam O longation/Agricultural ❑Industrial O Water Quality Monitoring DOW]SamplinglCharecteriatian <br /> ❑Public Water System <br /> IINRaam from O.ra: our syva,n avR t7ovuwt Nm or Phow u <br /> TYPE OF WORK ❑New Well ❑RWI.t Well ❑Well Alrention/Madification ❑Other <br /> ❑Monitoring Well(s) gofwellc ❑Soil Barings) a°lbanoa �Ototechnical serbadnst O <br /> ❑OutOf-Savice Well ❑Out-OfService Wall Renewal ❑Cross-Commetieo Repair <br /> ❑New parrom ❑Pump Repiectent ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Hoary Cl Air Rotary QEAuger ❑Cable Tool ❑Push Point 13 Other <br /> Proposed Well Depth ft Excavation in dumver ❑Open Bowan. ❑Gravel Pack/Gravel Sia in dlarnmer <br /> ❑Conduces " g in diamckr / Conductor Caning Depth ft 1 <br /> Well Caring Diameter_in Thicknea✓Gauge/ASTM Schad ❑Stsl ❑PIUme O Stainless Steel ❑Other <br /> Grout Sed Depth A ❑Nat Cement(94 1b bag/3-l0 gal wter) O Send C ant rack mix 17 pal water (� <br /> ❑Bentonite(20Ys wlida) ❑Mwufw[mer Spa%solids % Name a/✓ ❑Specs on File ❑Spas Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall E3 Other ❑Retardant/Accelerator(name) <br /> f1QIe4eL ImIzIoeaRy 13 Driller El Pump Contractor 11 Other <br /> [3Coa Pedestal Dimemba:Width A Length ft Thick m ❑Chrialy,Bos ❑Stove PI <br /> PUMP ❑3ubmeaibk ❑Turbine ❑Olhar HP Pump Ser R Studiag Wats irel It <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. �/)//J� j]�9�(� . Z� 91� <br /> M�I/NI HOUR ADVANCE NO ICE/`REQUUIR�E�D�FO�R IIP SPECTION <br /> TITLE 2'IDATE <br /> PARTMENT US ONLY �r <br /> /AyplHaann ngAj/arykd By J Q Arca Employs JD# <br /> "�.GFdTnapation By Dna PECIAL Wall PDTH& <br /> Pump lnspoetion By Date ❑ WAIVER RecelYed <br /> Cara ruew Wdl Depth n/J,�,�PP ' H <br /> COMMENTS �'HA 1W 44IPJ&7LW2 I7QL/ �.�BGf9l,!/' AL�Iri�L� <br /> PE SCRettivW ba Amount PormW InvskeY Wall IDN <br /> Cod" InroIlly, "h RamlaadPapSeevkewM Y <br /> 0,43771_ <br />