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\ WELL/PP1fP PERMIT . � SAV JOAQUIN COU.YTV EYVIROVNEVTAL 4 DEPARTMENT JOIE WEBER AYEJ" OCKTOY CA 95302-(209)468-3420 NON-REFUNDABLE EE�PERMIT CALL M /a,�CA�1}Ly`aL1 209 9�5533--)7697 FOR INSPECTION$ EXPIRES 1 YEAR FROM DATE ISwSSSUUEEaD/ ' JOBADDRESS � I 1 t rT� 1„V 1 �/ft+.` C."... `S! LE r ��V Yrl O CROSS STREET Gr;jVl+ M.1�.r1e�-��L�rlAa�� A/P�\'A 13 —O�—�L9 PARCELSIZE 9arres OW^.vEa NAMe G'l IrlibNQ- .—gO i�3. /t12W''Q (I/l r/L Pxove ^ g �.a r2C- ON'yERADDRESS T CITY/$TATFJZIP CONTRACTOR "d^��/I P -• txL . I fg.� �'g_ CONTRACTOR ADDRESS '3G% C�"jnin-( - 1 �`¢210 CITI'/STATE P f�.f( Il1Q. l 11 -SeAa2Y. SUBCONTRACTOR PNONE Z64 777 35'70 \ L f SUBCONTMCIOR ADDRESS CITY/STATE/ZIP aI�QY�AI�W�iFi/cA Z�L- r V LICENSE ✓ `C-67 ❑C-61 0D-09 �P❑EO�tther ryQ/y�� NUDI9ERUaUG= EXPIRATIOBDAie A GEOGRAPRICALINFORMTION: Coordinates 1I VIII 4- /ry gL1g1 �x Township_ Range_ Section INTENDED USE ❑Domestic/Pdvate ❑Irtigodon/Agricultunl ❑Industrial rp Water Quality Monitoring ❑Soil Sampling/Chaaaerization ❑Public Watersyystam Udiff Ilomener. .Ic+ note .m. omac, .moor one .m ter TTEOFWORR ❑New Well ❑Replacement Well ❑Weil Alteration/Modification ❑Test Hole El Other )tMonimring Well(,)_ "0mnmor-o"D MSoil Boring(s)_ a.mbn.1 Mnnaa ❑Geolechnieal numMofaorinyf ❑Well Deswction ❑O.'--Of-Scrvice Well ❑Out-ofgervice Well Renewal ❑New Pump 0 Pump Replacement ❑Pum Re air ❑Cross-Connection Repair WELLCONSTRUCr1ON Drilling Method ❑Mud Entery ❑Air Binary ❑Au er ❑Cable Tool Aush Point ❑Other r Proposed 1 Well Depth _fl Excavation=iodiameter ❑Open BDDom ❑Gravel Pack/Grovel lurcjV�jj indiameter Cl Conductor Cuing indiameter / Conductor Casing Depth C,27k2 ft Well Casing Diameter I in Thickness/Gauge/ASTM Schad ❑Steel pulaslic ❑Stainless Steel ❑Other Grout Seal Depth 1A ft .Neat Cemem f94166ug/5-10 got wore) ❑Sand Cement suck mixl 7 gal water ❑Mennonite(20%solids)) ❑Manufacturer Spec%solids_% Name ❑SPecson File ❑Specs Submitted Grout Placement Method ❑Pumped p/Fra Fall ❑Other O Retardant/Acceleatur(name) PEDESTAL Installed By XbrillR ❑Pump Comactor ❑Other ❑Concrete Pedestal Dimensions: Width R Length_It Thick in Christy Has ❑Stove Pipe PUxP ❑Submersible ❑Turbine g Other noM, HP Pump Set R Standing Weler Level ft WELLDESTRUCTION ❑Open Bottom ❑Gavel Pack ❑Uncased ❑Other Weil Diameter_in Total Depth It Depth to Water R ❑Casing to be Perforated from fl to_It Sealing Material ❑Near Cement(94 lb bog/5-10 gut emery ❑Sand Cement sock mu/7 gal water ❑Bentonite Pellets ❑Bentonire(20%solids) ❑Manuracmrer S,r%Solids % Name ❑Season File ❑Spre,submined ` Placement Method ❑Pumped ❑Free Fell ❑Other ❑Complete with Mushroom Cap_A below gnde ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN 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. j��j/// ;111NIN iAI241IOURADVANCENO'rlCtr"Fn111REED�yF�ORINSSPECTIONS ��/ SIGNED /J - r� TITLE r-��-f^I P%(!Un DATE//" V DEPARTMENTUS ONLY Application Accepted By Date Z D Area Employee IDn Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Dalc ❑ WAIVER Received Destruction Inspection By Date Constructed Well De th It COMMENTS rt PE $C Amount ChecWl/ Berthed Date Permit/ Involceil Well lDa Codes Info Remitted Cash By Senitt Be..estp EHD 43-02-006 crnpy Mancr water Well Permhdor g/20/200J