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WELL/PUMP PERMIT SAN JOAQUIN COUM ENVIOUNMENTAL HEAvm DEPAwrmEw JMEWEBERAVEJtn FL-SmLKTONCA95202 -(309)468-}430 NON-REFUNDABLEE PERMITCALL 209 99-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED J05ADMM 5/AO R'//f14 d0/J_ Cr" CROSS STREET APN 055- (� i2- P..coL�Ser. aZ7, G7 QG OWNERNAM{ A&#- 01,d/ y / PIONJ>QhWc?-45;70inz, q ' a OWNER ADDAg88 I-�/ n��/� yRfMI! 6-46 ' �'.}/-�y A� CITY/SYATEILIY �(+ CONTRACTOR WtS�T��](eOall / 'In 6 `-'T / iC Y./efi PHQ/R�E U�/J 31 & -.331.3 �y CONTRACTORAODRE58 G �� _A(, �/C" OZUt'Lf 1 CMISTATEZY `U/JI `tea `'� L 1/�� I^— O .Y1 /� SUBCOMRACfOR�f LN //�� Pll//�BE� SUBroNTRACEORAODEREEB`A)j0L- �^E CMIS'1'ATUMPP` Vy` LICENSE ❑C-57 D7^�61 13D-09 OOthcr 1 -O> I NUMBER 3O E%PIRATKNNDATEV67 '3� GEOQRAPHICAL INFORMATION: CBafdlnatel X Y Township RBnge_ SMtbn_ INTENBED USE 14Domcstic1Privam ❑IrriNtioNA{ricuhuml Oinduwdd O Water ON lily Monitoring ❑Soil Sampling/Cluatentaw. ❑Public Water S". Ifdimrml�hom Or W. rRem mematt naw nm. un r TYPEOFWORK 0N.Wel ❑Rcrloccme.t Well ❑Well Allmtio/Modlfiptron OTest Hale ❑Other ❑Monitoring Well(.)_ ❑Soil BoringU)_ .mnMrorlwdnss ❑CmRchnial "'a"kwafl,uk'B` O WNI DOWc6. ❑Out of-s r.xc Well OOutAMer icc Well R<dwal New Pum O Pum Re be .t ❑Punt,Repair O CmscConoecaon Kceir WELL CONSTRUCTION Drilling McBrod C3 Mud Rvery, ❑Air Run., ❑Auger 13 Cubic Taal OPush Point ❑Other Proposed Well Dcplh B Eammtim in diameter ❑Open Bottom ❑Grovel Pack I Gravel Sure-i.dlameer ❑Conducuv Casing ndianNtCr / CnnductorCMing DepN It Well Cuing Diamerer_in Thicm.VG.,c/ASTMSched ❑Steel p%astic ❑Stainless Sled ❑Other Grout Seal Deuh A C3 N.,Cement(94/h bag/J-IO grAxxK) OSand Cement .Aack mir/7 ge11411en ❑Bt.wite(20Yo solids) ❑Mmufacmmr Spec%solids_% Name ❑Specaan File ❑Specs Submilud Grout Ptacement Methd O Pumpd O Free Fall OOthtt ❑Rewdus/AcceLe amr(nea) PEDMAL Installed By O DMcr O Pump Contatm ❑Other O Concrete Pedestal Dimeasems: Width__ Il Length B Thick ❑Christy Bos OSeove Pipe Pump XSubmelsible ❑Turbine 13Otter HP Pump Set 4D ft Standing Wet.Level g R WELL DESERUCTN)N 13 Open Bmmm 0Gravel Pack 0Ummed 13Other Well Diameter_in Total Depth B Depth m Water fl O Caring In be Perfformed from_B In_N Smalls{Material ❑Not Cement(94/h/wg/J-f0b,ltwue) OSAW Cement slack Im./7gal water ORemomle Pell.. O Benronim(20%solid) O M...hcturm Spec%.fid.__% Nanw ❑Specs on File ❑Specs Submiped ` Placement MNEod O Pumped ❑F.Fell ❑Other_ O Complete with Mushroom Cap ft below glade, O Careplamw Eailting Surface Pd 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI,N},F(��JJ/UfM/2d'EEI/yyy��m/yO/'Tly-ADVANCE NOTICE REQUIRED FOR INSPECTIONS 91GN8D / v TITLE AT IN IL L: J A U DEPARTMENT USE ONLY Application Accepted By �L411Y/-ton. Date Q --A.7Arco Employee IDK IbQq Grout Impectian By No, ❑ SPECIAL WEII Permit Pumpinepcetion By ,�¢B54.d�6 Dole / P'i ❑ WAIVERRettived Devrucuru lmpcay By Y' Dare Constrocted Well Depth 0 COMMENTS I— PE I SC Amount h Recelvd Dune Permltl Invdce0 WNIlD# Codes I Info Hemmed ash By Service Reuvoco{ 3 0 s a7 0 W ;148 EHD43-02-006 MASTER WATER WELL PERMIT' 5072002