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L "M TT g.a..slI IV1TlI I1 gTJT.. <br /> / SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEMMMENi 304E WEBER Avg 3"FL-STOCKrM CA 95102 - 9)1611-YRO <br /> NON-REFUNDABLE P -'-•'^. (/J�/�) CALL(20/9)951-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> fn <br /> 30n ADORros O R, <br /> Cmyy?GP ��YY//VVIL// M <br /> CweaSneer <br /> OWN[R NAMg Y_l_CtY�'f YI Y ��"'(7}`) -17 <br /> PFONe_ <br /> OWNFRAMMM .-TL(,., Cf1YIS1'AT&Mw '1 <br /> CI nantAx OR r V// /.�7 ,P-HONE <br /> COIrtRALTOR AMRE®_.PD 3v\ft I '! 7� 0TVISrAT11211, WDOLL LIYlI.�1.A __ <br /> BURCONIItACTOR PHONE <br /> SUBCDNTMRORADMESN CEITISTATFRIP <br /> LICpi¢¢ C-57 0 C4 C3 D-09 OOther <br /> EEPIMnoN DATE r/'{� <br /> G60GMJMIGLINPORmATON: Caerdimtea % Y Towmhip Range_ Sttlbn <br /> INTENDED USE ❑D <br /> E3 Public Water <br /> System, 0 IrtigalioNAgrieuitml 13 Ind"rdnl ❑Water Quality Monitoring rc ivSampliyrChimaduralion <br /> ��U11 IlNrtmaram D.n.r aru nam nn --�-y <br /> TYPE OF WORN q New Well ClRephttmam Well ❑Well AlteaaoNModtBonvan O Tat Hole ❑Other m <br /> b p� <br /> pGmtecbncal <br /> Monitoring Weunumberarwlte <br /> ❑(s) $oil Bori ) <br /> s ivii°Q Orb^'"E' awaMdbd+O <br /> ❑Well Dearte iov ❑Out-0f-Service Well 0Out-0RServise Well Renewal <br /> O New Pum 13 Pump Repine ❑Pu 0. it OCroaConnectbnR Irt <br /> WCLL COXSI'RU <br /> Drilling Method Mud Ro ❑Air Rotary ❑Auger ❑Cable Tool OPYah O <br /> Point Other <br /> Propozd Well Depth Q R Eacavetion _in diameter ❑Open Bottom rIfrnvsl Pack/travel Sia iR diameter <br /> ❑CaMucbt CYfing iu diamacr / Cond Cvsmg Depth it <br /> Wall Coad., Diaeter�in Thicknem/OmnSeASTM Select 13 Steel Plaaic O Suint mel ❑Other <br /> Grow Sed Depth ogw A O Nea Cammi(94 to lwg/5-lO grd NvrerJ 'Sand Cemem �ir3 ,1uc11v17VI waren <br /> ❑Bemmnlm(2O%Solids) O Menul'actuier Spec%Solids_%. Name ❑Spmsmt File OSpes Submined <br /> Crest Plattment Method umpvd ❑Free Fall ❑Other n Relsrdmt f A,cela ---(name) <br /> PEDESTAL tau B rifler O Pump Contractor OOther <br /> Conerele Pedestal [Howard..: WidthR Length it Thick iv OChday Bos 051a"P(pe <br /> Pump j0pbttermble ❑Turnme ❑OtherHP Pum,Set A Standing Water Level A <br /> WELL DEYrRUCTION ❑Open Bolcom C2 Gravel Pwk ❑Unca%d LI Other <br /> Well Diameter_in Total Depth R Depth to Water R O Casing m be Pe,ma m,from_R m__R <br /> S"Jing Material 0 Nal Cement(94 lh Aay/5-/0gnf wRNr) OSand Comeri sant Sir/7 gal water ❑Bentonite Pellets <br /> ❑Bentenite(J0%a solids) ❑MsnufMtoaTSpec%solids__.% Name OSpeesee File ❑Spew Submitted <br /> Placement Method O Pumped ❑Free Fall O Other_ <br /> O Complete with Mushroom Cap R below grade O CmPkm an Esisling Surface Fad <br /> I 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 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �/��/�����( 1�t�I�NJ,,I�M�UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED I�9 `— Tau-41g!2! G4 DATE Zz <br /> 1 <br /> P � <br /> f <br /> / A 1 NT USEO.' Y -•W <br /> Apphlation Acrepled By Dam 3 Area _.L �Entploy"IDp <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump lnVeeuoo By a-L perm ❑ WAIVER Received <br /> Devwcdon InsFry on B Dam Construcrsd\Yell Depth R <br /> COMMENTS J20�d) 7.°O,iseLb>..1` �Q—��'2'-210' ,Te't"al1 <br /> I _ <br /> PE S[ Amount CheTkg Rttc <d Date 'emen Invoke# WeU IDp <br /> Cod" Info Remitted ah ServittR uwta <br /> 6 L3 <br /> 7 <br /> 0D Roo 463 <br /> PHD43-U2-006 MS-qq-(908q ,,/ MASTER WATER WELL PERMIT <br /> snrzoo2 qw-p E 19bi j&-f <br /> m7-35o-a1 � <br />