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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL h-..-.H DEPARTMENT 304 E WEBER AVE 311 x..-.,rOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE <br /> ��PERMIT <br /> j' CALL 209) 91.53-7697 FOR INSPECTIONS �1EXPIRES 1 YEAR FROM DATE ISSUED <br /> 01 <br /> JOBADDRESS v:.�� hW t. n(JN�hf1 G.f[T r1�y gT Y �j1�� 7 <br /> { M - / -1 CI�T�Y/ZIP{ OGK�nM _1 L3 i rya <br /> CROSS STREET t-TC'Y Ch C�L•wou, I r K^�"I"APN /I (qO'01 PARCEL SIZE J=(y�LAND USE APPLICATION# b� <br /> OWNERNAME IfZ 1�e'{'� 7C,J�t� 7 1 Gi�PHONE(2• � <br /> 37 9y y> <br /> OWNERADDRESS �Tl ' Z�-31,�I SC5 t/1 CITY/STATE/ZIPX-kr6rt!vld l q52-1(, ry <br /> CONTRACTOR ' �- 1 L.V 1 I\((�C, i C{' r`/ S PHONE 5�'/)26 O - 70Z G. <br /> —j �y T <br /> CONTRACTOR ADDRESS Z�L.(-►-eSc`,a �'P^�✓I CITY/STATE/ZIP t Y CIj F'NOJ /i <br /> SUBCONTRACTOR /� �1.��lN�I-Urj�� j�»�ri �."lG� —•PHONE( ! �p� <br /> SUBCONTRACTOR ADDRESS J��� TT r Sf-�. CITY/STATE/ZIP f"Y2�L1,Zj, � -I i ' vlfQ' <br /> r, LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE UZNa <br /> • GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdiff—ut(Som Owner: W.t. y:tem Mine -wa amem we Nuir7`0 <br /> i TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other T <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #orbor'ng' XGcotechnical I2I#of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> !• ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auugcr ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth!.i R Excavation 101 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other S <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-10gal wafer) Sand Cement (-C> sack mlz/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped ree Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL`'lInstalled By ❑Driller ❑Pump Contractor ❑ Other <br /> 1`' ❑Concrete Pedestal Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe (� <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft -�.. <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS 3 <br /> CURRENT AND ACTIV TH THE C IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS IO LAWS. <br /> MINE I 24!?!!�A�NCEMINE 124 R A NCE NOT.]CE REQ/UyAIIR.ED C"�'fi <br /> FO ASPEVS �( <br /> SIGNED TITLE r --'-'L�! �jc'I !U - U lY A <br /> ATE- <br /> \ V <br /> EETI <br /> DEPARTMENT UYE O)NLY <br /> Application Accepted B _ _ Date,,.,Y 1/ N Area 9 9 /f <br /> Employee ID# r <br /> Grout Inspection By Date-)/ ❑ SPECIAL Wel]Permit <br /> Pump Inspection By Date ` ❑ WAIVER Received <br /> Constructed Well Depthft <br /> .,c4:. e <br /> COMMENTS jam. � ,G. -Z{4 /k-0 /k S <br /> PE SC Received Ch k# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B C Remitted Service Request# <br /> ,7� 0�-q SYO ah-9 loi -�-#001/7 q E-�Z <br /> END43-02.006 WELL PUMP PERMIT <br /> imrzo0s <br />