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WELL/PUMP PERNIIT SAN JOAOUIN CW.Wy ENVIRONMENTAL HEALTH DEPARTMENT 304EWum Avx3"F-L-SNc% ONCA95202 -C2091468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOBADDRESS ..:i o 7n�.re4 -74n' c[Tr/2eP57 s / 7 9 CROSS STREET ,(�PY APN� 3 �( / 35-- PARfP.L$rZE� m a O\VNex NAME � �� C/ PHONE /V� CSR-IcIS OWNERADDRFSS / L//f ('0/1/0 n fJ-A! CIIYISTATEJZIP tU CONsLTOR PHONE CONTMRORADDRENR CIT'ISTATF/EIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/SfATeuMP Q LICENSE 1:1 C-57 9661 13 D-09 ❑Othe! NUMBER EXPIRATION DATE GEUGWIII ALINFORMATION: Co..did.m % Y Tdnoahip_ Raagc_-_ S«Ywn INIENDEDUSE O Domatic/Rivyte ❑I'dipriondAgdcvlmnl ❑lodustdal O Wamr Quality Mtmhming Cl Sail Sampling/Chamementsied ❑Public WBty Synsle m IfdlxeNn"n Or w r roc" a"e C.ha Nonc.r k.u r TYPE or WORK 13 N.Well ❑Replacement Well ❑Well Allmtiam Modifiettion ❑Test Hale 13 Other ki ❑Monitoring Wells)_ rw" ory u, p Soil Boring(s)_ canto.,°rw—w ❑Gcmechnicol ""' .rh.dns' Cl Well Duction Xput-Of-scr�ice Well ❑Out-0eSernce Well Reorwal ❑New Pump ❑Pump Reafxamcnt ❑Pump R air ❑cco econnemion flfr WELLCONSTRUCTION Drilling Method ❑Mud RDury ❑Air RDury 0 Auger ❑Cnble Tool ❑Push Point ❑Other Proposed Well Dr Kh fi Exe.tnon in diameter ❑Open Bottom ❑Gravci Psck I(;.I Six indi.dnmcr ❑Conductor Cssmg iadiameRr / Conducwr Casing Depth _n Well C.4.g Diameter_in Thickm,WGsugNASTM Schcd EIStoK ❑plead, ❑Stainless Steel ❑Other Croul Seal Urysth ft ❑Neat Ccmcnl(941h hug)3-10bdwoler) ❑$and Cemnrt orck sn&/7&I water ❑Bemonite(20%solids) ❑ManuBctunw Spee%solids % Name ❑Sitce...File ❑Specu sAmined Grout Placement Meshed ❑Pumped ❑Free Fall CI Other ❑ReMnIuntI Accekm0r(name) PEDESTAL 1.0.11ed By ❑Ddller ❑Pump Contractor ❑Other O Concrete Pedrstal Dimenafons: Width_ R Lcolph 11 Thick in ❑Christy Box ❑Stave Pipe PUMP E3 Submersible ❑Turbine 13 Other HP Pump Sel n Standing Water Level R WELL DESTRUCTION 13 Open Bottum ❑Gravel Pack ❑Uncaved 13 Other Weil Diameter m Total Depth ft Depth t.Water A ❑C.,to be Performed Boni fi Io R Sea.,Material ❑Nat Cement(94 M A,IJ-10gul wnrea) ❑Ssnd Caner .dd*mix lT gal waver ElBemmmim Felle¢ ❑BdAmphe(20%salid.) ❑Menufecwrer Spec%sulids % Name ❑Spscson Filo ❑Spees$ubmiped Placement Method ❑Pumped O Free Fall ❑Other ❑Complete with M ushmom Cap it hNow grade ❑C.mpldc to Exining Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE UN 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQLI IRED FOR INSPECTIONS SIGNEp TITLE DATE IngI DEPARTMENT USE PNVI A,lieation A eerytrd By " Duwj7—f Tj_ OZ Ara � Employ.111 (_ Grout��n��ei.n�uun By Dale -'�1 ❑ SPECIAL Well Permit l.e� (Jr .li t,<t sty/i ry,�l�!?%fC..;f 11WAIVER Received famp-MRembsBy Destruction Inspection By Dme - C..w.cled well Depth B COMMENTSg'W-- 7i [' .• ! ��.v e- I aR r r PE SC Amount v Received Pcnnnl' Codes Info Remitted Cash B Dale Service ft ue.,# InvoieeX Well IDN 0 no /e ! P.. OL''3 EHD 43.02-M MASTER WATER WELL I•ERMIT' SR12002