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JOY) <br /> — WELL/PUMP PERMIT — <br /> SAN JOAQUIN COUNIYENVIRONM9WALHGLTN DEPARTMENT 304E WEBER An 3"FL-SrocR70N CA 93202 -(209)46&3/20 <br /> NON-REFUNDABLE PERMIT '-- "•` CALL 209 953-7697 FOR INSPECTIONS - EXPIRES4 YEAR FROM DATE ISSUED <br /> qua :�ezi fid, .. Sb�KIv Gs:?'Q <br /> JOB ADDRE.ffi O CTrMir <br /> fyAy� VIJ� R t APN n O- _PMCEL SIL¢ r-J.AND UBC APPWGTONp S <br /> CRo69 STRRe1' Giaa i± 1 1. <br /> OWNLRNAMLS-V' S9B41y .P4fTkC�JTLiQ .Vethe♦ A.. CSa+..�. Pxonc aOCl�43l-471--p._ La <br /> OWNER ADDRESS GlDaa f. Comm- JIL Rd, \ COY/SrATPZP StKN c.4 •�1.�a)J+ <br /> GONIRAtTDR R.'u!' . ��IYIPNonB Qo5A--9iig-0-139y <br /> COM'RACTORADOR Y•o•'0DY/ via - CIIY)6:i^—�C�AiTVLIP r/) c��✓//T��TgqYsa <br /> glmCOnTIL1J'fOR / PHONE Ze7 -3,ggiS <br /> SUBCONTRACTOR ADDRESS _ • CT/STATFJZRCb <br /> .. . <br /> LICBnea ❑C-57 CC-61 0049 'OOther MIOIBER 8566QJ Etammu TIONDATEOJ/e°asi' ^1 <br /> GLOCRAPHICALINPORMATION: Coordbutm,X Y, TOWnMP Range- 9 <br /> 1 No t wP ODomaticft u, Im9AtioNAFimlNnl 0Induatrhl O Wuer QuditY MOnitoring - .O Soil SampIm,,/Chmactedmtion <br /> O Public Wattt Syrtem <br /> Udineew6am= _ e m m,.ae um <br /> TYPE OF Won O New Well O Replacement Well _ Well AlRntioNModifialwn SlOther k VN :r"j-6144i^ <br /> • OMoeimring Well(e)_ r <br /> pofwelIs , OSoil Boring(s) sofServ,p Odeoechniml MOTLoenp <br /> O Out-Of--Service Well 1 . . 0Out-045erviw Well Reumn] OCrossConnmumlteprir. <br /> UNm01`umpflucbsccrecel .I O Purup Repair <br /> WELLCONBTRUCTION NSA <br /> Ddllme Methad I7 Mtid RoWy ' Cl Air Rotary -''s O Augcr -' O Cable Tool ""O Push Point O Other <br /> Proposed Well Depm 'ft � Exuwtion " in diameter OOpen BOtmm OGMvel Pack/Onvel Sim. in diimeta <br /> 4 <br /> i ❑ConducraCuing in diameter / Conducmr(ksing Depth fl <br /> Well Cuing Diameter_in Thickne".ugdASTM Sebed 0 Steel O Plastic . O Stainless Steel O Otha •' <br /> Grout Sed Depth ft O Nut Cemmt(94/b bug/d-IOgal wafer) O Sum Cement saek meth/7 gd water <br /> O Bentonite(20'A solids) O Mmufwwm Spa%solids_% NurR - O Specs on File O Space Submitted <br /> Grout Placemeot Method OPumped OFrm Fall -OOther- - OReurdant/Aceel6tor(wne) <br /> $pgg2Al,Vt/¢InelaUed By et Drilla O Pump COnD¢mr O Oma <br /> JIM- OCascde PedmW Dlmendom:Width;'' - fl Lmeng ". flThick In OChrbty BOE OSmw Pipe <br /> OSubmmible ❑Turbine 000w HP Pump Sel ftSetading Water l<vel ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE'WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATION& 1 ALSO CERTIFY THAT-MY REQUIRED LICENSE IS <br /> CURRBNr AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE-LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS CONURENSATION LAW& <br /> FINE!I <br /> MIfJJ�1UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SaneD /L � y.-►� Tree IG/v�',� . . DATE O � <br /> t r <br /> op <br /> I <br /> E <br /> I <br /> wo <br /> I <br /> D A iMENT PSE PNLY,, - <br /> Applicatlon Accep Dam Arm EmPbyee IDN't2 T f"1 <br /> Grout Inspection By' Date 4t .17. SPECIAL Well PermR .�. <br /> ' On Dte O- WAIVERRecelved <br /> Canurmted Well Depth _ It <br /> COMMENTS �+ <br /> 1 <br /> ' PE SC Raelvad Amount - Perdu - - <br /> Dale Iovolu# Well IDN <br /> Cadet Info B Cmh Remitted Request <br /> -7 N 0� • . <br />