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It r3 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMEWAL HEALTH DEPAt1TMEM 301E WEBER AVE 3—FL-SIwaxeN CA 9520E -(299)40-3120 <br /> NON-REFUNDABLE PERMIT /C1.}1A�(LL(2209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED w <br /> JOBADDREStS in ��� e, r�'-� • �k C.IZIP L✓� �ti S Zr�I� <br /> �& -s+, c� � c ° <br /> CgOSB grReNT AP/N' PARCEL Stu 119 LANDUSEAPPUCAnonp <br /> OWNERNAME ,%m I IMA O O i? "r� � TLQfCCP PRONE <br /> OW WRADDRESS COY/SfATVGP <br /> CONTRACTOR 1 r(�)FELD ER- " % C _ PHONE OnCz-tq. t 1'-- <br /> n <br /> COMUCrOR ADpavca -J - �/7•r�-6�` • C-1STATL/ZIP <br /> - - r_f_ <br /> SUBCOMMCTOR PRONE <br /> SUBCOMRARORADDREES C"ISTATIcal, �/J <br /> LICENSE -57 O C-61 II D-09 ❑Olber NUMBER EENRATION DATE '/J Ll l 10& <br /> Ge RAMHZALINMRMATION: Coordinates X Y Tawdhip_ Rage_ SeetloR_-- <br /> INrtND[DUse ❑DomeatirJPri ,e 13 Inigawn/Agnmitural CIndustrial ❑Water Quality Menitonng 0,rLl Sampting/ChWeledation <br /> OPnblic Waters tem �« <br /> ud,O�r aon,�.M.: .m r.mn .o,e <br /> Tm OFWORR ONew Well ORepla ont Well O Well AltentiodModi6ntion Omer efbuino <br /> xormda IxGeohchrocel�_x <br /> O Monitoring _g ofwelb []Soil Borings) �l <br /> C]GYt-0f Serviec tt Well ❑Out-0f--Service Well Renewal ❑CrwsConnection Repair ,I1 <br /> O New Pun ❑Pump Reptaceownt O Pump Repair <br /> watconsrRurnon <br /> Drilling Method ❑Mud Ronny O Air Ronny Auger y [3 Cable Tool O Push Point ❑Other <br /> Proposed Wall Depth W-2-0 ft Excawti..�ein diameter ❑Open Bottom 0G.d Pack/Gravel Sim in diameter <br /> ❑Conductor Casing iodiameler / Conductor Casing Depth ft <br /> Well Casing DiMMer_in ThickneWGauge/ASTM Schd ❑Steel ❑Plastic 13 Stainless Steel O Other <br /> Grout Seat Depth R O Nest Cement(94 lb bag15-10 Role a,) ❑Sad enl�_ Csad ma/7 gal caster <br /> [I Bentonite(20%solids) ❑MdulYdur r Spec%solids_% Name /1 1/'w O Specs on File O Spas Submind <br /> Grout Placement Methad O Pumped ClFra FA O Other O R ardent/Acalentor(am A' <br /> PERM& inatWedBy ODnller ❑PumpCmmwr o aha \� <br /> C3=Patients] mmeudonr.Widthfl L gth ftThick io 0Christy Bos OStan Pipe <br /> ❑Submmible O Turbine O Otho HP Pump Set ft Surfing Water Level ft <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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MUM 24 HOUR ADVANCE NOTICE REQ UI ED FOR INSPECTIONS <br /> Simae A ""' Lia{'L- TITLE CALK DATE 3 O <br /> F U <br /> I N1 <br /> FIN <br /> JUS <br /> yy Win. DTMEN�e�� <br /> lam. Ix3%.e.F�led By MeAtaLroM Inspection BDateO SPECIAL Well Permit <br /> Fump lnspeetio,By - :. Dau Q WAIVER Received <br /> Coostroeted Wall Depth R <br /> COMMENTS <br /> PE SIC R.-; d Cb.W' - Amouht- _ Data - - Permit/ Inve.kc# - wen RM <br /> Codd [of. E Cash Remlttd SeMhe 111,4111ast e <br /> � 11 (� 1114 L qb <br /> L <br />