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WELL/PUMP PERMIT 3 9 Go +��d SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMLNT 304 E WIDER AVL 3-FL-STocwrON CA 95202 - (209)4611-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED p I - _ - � Joe ADDRESS S�d+^4t.h �aw�t Pwr Crrc �lLtP/► 1 f Ci vl /J 93 > CROSS STREET �' S APN 2.616 p 01-(e P,i 249 ZE/G9.n"'LAnD Uu APPuuT*N N OWNER NAML LI(", ,( Sp��1 T•r� PHONE OW14ER ADDR[ea Y"t``t CrTY/STATEMP CONTRACTOR PHONE CONTRACTOR ADDRESS, 1 CTTY/STATLMr /�!J SUeCONTYACTOR Kl,;4G..l�A-f C 1' PHONE q LqFr SUDCONreAC.�TOOR ADDRESS 2'491-5 G. Kyf Tlli CITY/STATEMP S�n /E �S Lt:V= A(C-57 0C-61 0609 11 Other NUMDER y672$ L EXPIRATIONDATE GEOGRAPHICAL INPORMATMN: Coordinates X Y Township Range Se-do■ [N17S/t/LD USE ❑Domestic/Private ❑Irrigrtion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactcrinuon ❑Public Water System If diff..d floe Ur.c Wr syrs N— C°wa —or TYPE OF WoRx ❑New Well ❑Replacement Well ❑Well Altcration/Modification O Other ❑MonitoringWell(a) Mofwdla fFDesisg(s) tore I((Geotechninl Z aottwrsy _ ❑Out-Of--Service Well ❑OutofScmce Well Renewal ❑Cross-Connection Repair ❑New Pum ❑Pump Replacement Cl Pump Repair WELL CONSTRUC714fi �1 Drilling Method [3 Mud Rotary 13 Air Rotary XAu E3 Cable Tool ❑Push Point ❑Other Proposed Weil Depth 10 R Excavation yT in diameter ❑Open Bottom ❑Gnvel Pack/Gravel Sia in dwn+erer Cl Conductor Casing in diameter / Conductor Casing Depth ft Weil Casing Diameter_in Thickness/GaugOASTM Schad ❑Steel ❑Plastic ❑Stainless Steel .11�00- Grout Said Depth ft ❑Neat Cement(941b bag/J-10gal water) p Sam Cement T mix 17 gal"ter ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placemeat Met►od OPumped ❑Free Fall ❑Other ❑Retudant/Accelerator(name) =MIXA4 Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Cosersla Pedestal Dimesalous:Wldti R Latgth ft Thick m ❑Christy Be, Cl Stove Pipe ❑Submersible ❑Turbine ❑Other HP Pump Ser H Standing Water Lev ei ft 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. 1 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 REQUIRED FOR INSPECTIONS S [� 0, + SIGNEDTtTLE T's P [S S ,.e,4I DATE 7,Za . r Q ------------- DEP RTMENT U E O LY 'JrOfY� Application Accepted By Date O A. Employee IDM �! Grout Inspection By - pate A ❑ SPECIAL Well Permit yQ Pump ItutpecrioD By Date ❑ WAIVER Received // Constructed Well Depth It COMMENTS -/ �tf-[�S loL�iY{.�--J.e-r 14daiy-, 61yo V-1532 - r7HLin.G1'K� PE SC Receivedk#/ Amoeet Perdt/ Invoke# wen IDM Cod" Info Y Reesitted pal Request M d 0 WELL PLW PERMrr EHD 414-006