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WELL PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENYIRONMEMFAL HEAL'EII DEPARTMENT 301E WEBER AVE J"EL-STOCI(TON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 957-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m <br /> Z,0o n'3re� �'TJJC.�'7 <br /> CITY'De <br /> JOBADDRE53 / T <br /> CROSS STREETL p ,f.�t— PARCELS= <br /> �I / /d�2 �CJ�S /453 —93-3/ Fnon <br /> OWNERNAME ••�� /l �j may/ �5'CIy <br /> CITYISTATFILIP� �n4f lrea� r/1" SJ <br /> OWNER ADDRESS y <br /> CowmcnrOR L ee—�� PIIONElo9�9yb'—�31y� <br /> COIDRAfORADDRESS � ' /c-ne— vis. 'o z. <br /> SuxcoSTrr rn 1.vJ PNonE�D9?1Si6s d'�-/L <br /> NrxAcrox _ <br /> / �/�'�r (,J� CITYI$TAT FlLIP STN•/yµ1 (���jJ� rT <br /> SVBfONTM �I\V- <br /> CI'OP ADU0.E55 �� -11—/J/� <br /> —` ?7 <br /> LICENSE C-57 ❑C-61 0D-09 ❑Other NUMBER .S/�-Z60 E%PIxAT10N DATE /yam/j J <br /> GEOGRAPRICALINFORMATION: CHOrdlnel" X Y Townchlp 3�RangeSection N/ <br />( IMENDED USE ❑Domestic/pnVaM ❑longationJAgriculmml ❑Induamut ❑Water Quality Mornomng ❑Soil sompunp/Chm.......on <br /> _ ❑ Rbal W"I.B�s¢^m ... cont- +nix o� ionv <br /> ape, loo <br /> us <br /> T11EO1WORR ❑New Well ❑Replacement Well O Well AllerelioNModiOcubtro ❑Test Hole ❑Other wnixr arbannV <br /> ❑Monitoring Weil(s) numbeeor.Jb ❑Soil Bonng(S) nameer orha,ings ❑G.RRhmcPl <br /> ueai -Of-S Well Renews] <br /> >01,11 DcsoctoWelty ❑Out <br /> ❑New Pncemcnt � mOGr <br /> ❑Cross- <br /> 11 <br /> WELLCONSTRUCr1ON <br /> DrlllI.,Method ❑Mud Rotary ❑Air gets, ❑Aug<r ❑Cable Tool ❑Push Po <br /> Proposed Well D,th II Excavmiort in dometer ❑Open Bottom ❑Grovel Tac ruv<IS ineinntner <br /> ❑Conductor Casing in character I Conductor Casing Depth 0 <br /> Well Caring Diameter_in TmcMwAvGauge/ASTMSchcd ❑Steel ❑Plastic ❑sem less Steel ❑Other <br /> vauk nrl<I] water <br /> Grout Seal Depth It ❑Neal Ceraem(941h hag/3-10 gal-1111) ❑Sand Cemcnl 6a <br /> ❑Oemm�lle.(20N.Solids) ❑M.mEschorSpec%solids _ % Name ❑Spas on File ❑Specs SuM1ntlmtl <br /> FYICroat PI¢emem Mmhoe ❑Pumped ❑free Fall ❑Other ❑Raardant/Accclemlor(name) <br /> PEDESTAL Insleletl IIy ❑Driller ❑romp Commcmr ❑Other <br /> S ❑Cdi ig Boa ❑Stove Pipe <br /> '00 <br /> ❑Comtel.Pedestal Dimensions: Width li Length 1t Thick Y pe <br /> PUMP ❑Submersible ❑Turbine 0OIM1er pP_ Pump Sm II Standing Water Lwd IT <br /> WELL UESERUCI'ION ❑ p[t UnDom �v r Ey-p❑U-CeS[d G111 r ( UI -11 <br /> FVJ <br /> �—Well Dimachd J INToul Deply' /2" fl-DePth to Water�i�ll �IY.haam6lo be Perlorutd lrom �Qf It to <br /> SnIBrg Material ❑Neel Cement(9,lh h,15-I05alusuer) and Cement An h 17galwmer ❑Permute.suets <br /> .n1 <br /> ❑MnuaulSpec ❑Speer on fre ❑Spec fnrcJ <br /> ❑Bmmmm(20%solids) , <br /> Placem <br /> Metho <br /> er <br /> HERE Y CERTIFY <br /> '1Pu I H ❑Free Fall ❑A I I <br /> ❑Complete with Mushroom Cap 11 below grade omplem to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANDSTATE LAWS,AND RULES ANDLAT THE WORK WILL OE DONE IN ACCORDANCE WITH SAN <br /> CUIS <br /> RRENT AND ACTIVE(WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARDOAND THAT I AM IN COMPLIANCECERTIFY THAT MY REQUIREDLICENSE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ <br /> SIGNED <br /> TITLE 7/ DA. �2' �D rf <br /> 1 <br /> R E( <br /> NI]. 11f <br /> EPARTMENT US N Y <br /> Application Accepted By Date 213 Area Employee IDM <br /> J Gram Inspmtion❑ Dem ❑ SPECIAL Well Permit <br /> 111 Pump Im,ectlonB Date .21-0� 1�22A2, ❑ WAIVER Received <br /> D<stme ion Dme Constructed Well Depth h <br /> COMMENTS ' <br /> PE SC Amount I Iierelve0 pure PermW Invoice Well IDY <br /> Code, Info Remlited Cash By Survlre Re uesl p 1 <br /> qy� rN � L10-7 ! 3 3� <br /> 3 3� <br /> (p.Nq 5y T7 111 5 3 3 5 <br /> MAST IJ<WAIEII WELL PERMIT <br /> EHD 43-02-006 <br /> 5I]0002 <br />