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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENYD0.0NI.SLNTAL HW :PAR2'tAENT <br /> 600 E.Main Street-STO N CA 95202-(209)468J420 <br /> NON-REFUNDABLI1E PERMIT "A� CALL 209 9534697 FOR INSPECTIONS EXT'ztat eS 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS dO C1Tvalp 'S CKz� S'Z s I <br /> '3A-- I <br /> a tlss Arrucwntxl Y„ <br /> CROSS STREET <br /> uw tNN�n�/RR _ . <br /> �oP. ON'•� Sf�QATOChR CA ran, HS <br /> DD Ft>!z t cn a E2c . ani Ads' .: Hazelton <br /> ASS <br /> a' :{ Delta Pum PuoNe 209-4 - O DINATORS <br /> s ert McClell n,REHS <br /> a.• ttcss 646 S. California Street" - Cctv/STwTF/LIP Stockton CA 45JJeff Carruesco, RE11S,RDI <br /> • PRONE �- S <br /> C ` Re <br /> �` ....•' CI'ORADDRUS �- ISTATE/ZIP �- <br /> Linda Turkatte, FENS <br /> LtcPNse 0C57 XZG61 OD-09 13 Oth.r4 724778 ExPIRATIONDATE 08/12-. <br /> GEOGRAPHICAL INPO TION: Coordinates X Y Townsblp Range Section <br /> �jr zNDSD Use Domestie/Private Q Irrigation/Agricultural O Industrial <br /> Water Quality Monitoring t]Soil Sampiin7/Cheracterization <br /> Qbllc Water$y�tem uea or r <br /> tr4ftl atom bwna: "W spune <br /> jyJLOF WORKNew Well O Replacement Well O Well AtterationlModificatioR OOther aortariagr <br /> aorborlats pOeotechnicsl <br /> D Monitoring Wells) M Of wells D Soil Boring(s) J <br /> O Out-Or-sarvice Well O Out-Of-Service Well Renewal 0 Cross-Connection Repair Q <br /> hKNew Pump O Pump Replacement D PUMP Re air <br /> WELL Commurnag, <br /> Drilling Method D Mud Rotary O Air Rotary O Auger Q Cabin Tool O Push Point O Other <br /> Proposed Wen Depth R Excavation in diameter O Open Bottom A Gravel Pack/Gravel Simin diameter t <br /> OConductorCasiag In diameter / Conductor Casing Depth ft <br /> Castes y, <br /> Well Diameter Tin Thickness/Gauge/ASTM Schad O Stocl O Plastic O Stainless Steel D Other ^t• <br /> Grant Ssal Depth a O Neat Cement(741b bag/5-10gal water) O Sand Cement sack mle/7 gal water ^ <br /> D Bentonite(20%solids) O Manufacturer Spec%solids_% Name D Specs on File O Specs Submitted �) <br /> Trout Placement Method OPurnped O Free Fall O Other O Retardant/Accelerator(name) <br /> i <br /> PED , Installed By O Driller mp Contractor D Other <br /> •D Coaerete Pedestal DI nslo s;Width ft Lea ft Thick In D Cbrlt Bo: O Stove Pipe <br /> Submenble O Turbino D Other IIP Pum Set ft Standing Water Lovcl ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TEAT 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 1"J <br /> CURRENT AND ACTIVE WITH TSE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITII ALL �A <br /> WORKERS COMP SATION LAWS. t <br /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGN TITLE CEO DATE <br /> rT— <br /> E I N E <br /> b EF TR T M-"-T IFS" --O'N L V — --/ �--�- <br /> Application Aecepted By Date Area lk Ar rr Employee IDr b i <br /> .7&3 e�Q <br /> Grout Inspection By Date ❑ SPECIAL WellPCrWlt / <br /> Pump Inspection By Date Cv ❑' WAIVER Recelved <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received telJf Amoubt Dale Permit/ Invoice well MN <br /> Codes Moro . B ash Remitted Service Re'" <br /> r ue t0 <br /> b I <br />