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SAN JOAQUIN COuNTY ENVIRoxRENTAL HEu rN DEPART WELL /PUMP PERMIT <br /> NON-REFUNDABLE PERMIT 600 EAST MAIN STREET-STOCNTOM CA95202-(209)468-3420 <br /> J �s CALL '209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> F:OWMNERADDREM <br /> /��aq C' -/j <br /> T APN O� v3�r7 2.. nPARCELSME�y�]jtLAryDUSEAPPLIDATOXi)_ PXONESS I ADDRESS_ 2a 1 AX-A, ,,,— Vd, Cm/STATEZP_ 57oc Z;� <br /> SUBCONTRACTOR /J - G, PHONE /.90 1 <br /> SUBOONTRACTORADOREss a74 44,;11Tya ,QJ CITOSTATEMP Sr h /Ca 95.7 <br /> o , <br /> WENSE 'i C-57 Cbl I D-09 L Other NUMBER 6S6?X7 F"juTpx DATE <br /> GEODRAPHN;AL INtR1RMATION: COOrdinat*$X V Township_ Range_ SecUon_ Vr,� <br /> IHrEXDED USE : DomestrcJPdvate ImgatiortAgrioullurel Industrial ❑WaterOWI1tYMONtodng .,Soil Sampling/Charadanra0an 1^_ <br /> -:Public Water Systz <br /> em --- <br /> n aMment exm o.ner a ern emo ame or mw um <br /> TYPE OP WORK 7 New Well Replacement Well Well AlleralionlModi8ca0on Other m <br /> -.Mormodng Well(s) Sof wells :Soil Boring($) 0dE.l, Geolechnical�Mo1padipi I , <br /> [. Out-Of-Service Well Out-OfService Well Renewal CMSS-Connection Repair <br /> New Pump 11Pump Replacement Pump Repair w.RaiseWellCasfing <br /> WELL CONsmauctx*i <br /> Drilling Method Mud Rotary Air Rotary \,Auger Cable Tool " Push Point - Other <br /> Proposed Well Depth 25-So ft Excavation C in diameter :Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing In diameter I Conductor Casing Depth R <br /> Well Casing Diameter_In ThlcknessJGaugefASTM Shed I Steel Plastic Stainless Sleet Other <br /> Grout Seal Depth S T Neal Cement(94 lb begS10 gal water) Sand Cement sack mixll gal water C <br /> Bentonite(20%solids) Other <br /> Grout Placement Method N Pumped : Free Fall :Other Retardant/Accelerator(name) <br /> PWexTluL Installed By Driller ❑Pump Contractor - Other <br /> Concreb PedestajDlmenslons:Wdth_ft Length ftThick In ❑Christy Box _Stove Piles <br /> Pump Submersible :Turbine ::Other HP Pump Sel ft Standing Water Level ftjE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 9AN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 S. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED !✓ TIRE /e�K% �ir �/ DATE <br /> 1 <br /> N R E <br /> 7 IV NT <br /> DEPAT-*SNT USE ON - <br /> _ — Date_ Area__._ - EmployRee ID#JY1,1 <br /> ApplicationAccepted Y RSPECIAL Wall PBRIt ''77 <br /> Grout Inspection BY Date <br /> to WAIVER Received <br /> Pump Inspection BYted Well Depth <br /> ft <br /> Soil Boring I n BY DeMLt <br /> g � onetrwc <br /> COMMENTS IV <br /> pmourA Dab PermiU Invoice A Well[Do <br /> PE SC Resolved Caah RemRbd So wast% <br /> /SDI ',�I 134;-7 -7i-7 SX00403 <br /> WEU RUMP pEleaf <br />