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�' WELL/PUMP PERMIT - 990 JAN:IOAQUIN COUNTY ENVIRONMENTAL Fj{ NDEPARTMENT 304 E WEBER AVE °f- 1oCttTON CA 95202 -(209)46&3429 IVON-REPUNDABJE PERMIT I CALL(209)953-7697 FOR INSPECTIONS EXPI FFL 1 YEAR FROM DATE ISSUED JOBADDRESS SOUS F- IC0 A-^-,0 L 7 /+/� Y CITV/Ztp F ✓ m CROSS STREET i Q N r.a� 7"I TT^ rJi�—(J t(d_l PARCEL SIZE ' DMS ¢ I x-'/7 W . OWNER NAME F _4!. 1-lltV�� n� �p�;�..�y..,., - PHONE OWNER ADDRESS •�'-d'y- l yC)YI$ T1'ATEIZIP CONTRACTORL r� PHONE ;oto CONrIRACIURADDAESS g O >17 CAf �ss,l 5 ? CITY/STAVFMP Cn' StisCONIRACTOR COt"- L-11. // /PIIRNE .t SUat.DNTRACI'DRAbbRESS Sq ` YO 6/0 �OC CrTY75TATPJZrP 'P. ClJ 'lgrS�,�'y LICENSE 'KC-57 ❑C-61 Q D-09 ❑Other M" NUMBER E%PIRATION DA E U 66 GEOCRAPHICAL INFORMATION: Coordinates X Y Township— Range Section INTENDED USE ❑Domestic/Private ❑Irrigalion/Agricultural O Industrial. 17 Water Quality Monitoring 'Sail Sampling/Characterizalion ❑Public Water Sem IfdiNereM fmm ater yrlem amt om or ne um - TYPE OF WORK C.3 New Wel] ❑Replacnncnt Well 0 Well Altemlion/Modification E 3 Test HOIe 13 Other number otwcns [7Mani lorirtg Well(s) Soil Boring(a) tio.2op-1-o��Dr', �Crotxhnica] nuaaaorbadnpy D Well Destruction ❑Out-Of-Service Well Vm_ 7C1 t-Of-Service Well Renewal O New Pump ❑Pump Replacement Q Pump Repair ❑Cross-Coemection Repair WELL CONSTRUCTION ��,,,.../// Drilling Method ❑Mud Rotary ❑Air Rotary )(Auger Cl Cable Tool ❑Push Point E]Other Proposed Well Depth 10-3-57 R Excavation `` in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Cadng Diameter_in Thickness/Gauge/ASTM Schell O SweL ❑Plastic 13Stainless Sleet ❑Other Grout Sent Depth R 0Neat Cement(941hhag/S-1pgulr 111, 13 Send Cement .rue*micl7gaL wafer - 1 ❑Bentonite(200/solids) ❑Manufacturer Spec%solids^% Name O Specs on Filc 13 Specs Submitted Grout Placement Method L7 Pumped 13 Free Fall ❑Other ❑Rsardant/Accelerator(name) - PEDESTAL installed By 13 Driller ❑Pump Contractor El Other I d Concrete Pedestal Dimentioas: Width_ft Length R Thick in ❑Christy Box ❑Steve Pipe, PUMP O Submersible 13 Turbine ❑Other HP Pump Set—fl Standing Water Level 11 WELL DESTRUCTION ❑Open Bottom ❑Grove]Pack 0 encased O Oihcr }, Well Diameter in Tota]Depth R, Depth Io Watcr R ❑Casing to be Perforated fromft [o fl '[ Sealing Material Neat Cement(1114 1b hug/3-1 pgal xwter) 13 Sand Cement suck mix/7 ga]water ,❑Bentonite Pellets ❑'Bentonite(201/6 solids) ❑Manufacturer Spec%solids_a/. Name E7 Specs on File Q Specs Submitted Placement Method 0 Pumped 10ree Fell 13 Other ❑Complete with Mushroom Cap' ft below glade ❑Complete to Foisting Surface pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN 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. MINIMpm OUR ADVANCE NOTICE REQUIRED� fFOR INSPECTIONS (/ SIGNED TITLE 1'K6C(Z�Or DATE (I t ar of 4t at 14Y�1+ "• _ A- J' - K a PCx , Application Accepted By c Date 141 GG1ffS D f Area f d Employee IDq �� f 57 tto Y . D2Ie-�jfe�fF,� - ❑ SPECIAL Well Permit Pump Inspection By --- Date: 17 WAIVER Received I Destruction Inspection By ` Date - Constructed Well Depth ft COMMENTS ,. e , ' dO�l/ .Z 6 h a td - 6 r- , PE SC Amount Checkltl ReceivedPermit/ 4 Codes Info Remitted Cash B Date Service R uest p Invaicell Well IDk 43-72- fsa 3c ra 35 i CH D 43-02-006 5/72062 MASTER WATER WELL PERMIY d }