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CITY/STATE/Z. SLINCONTRACTOR ADORES% <br />C-81 0-09 NuMOCR (41162132L Ear.PiMATION DAMS A..C., o <br />Coordinates X ____ Y <br />Township Range__ Section__ <br />Ovate I tritgationiAgrlcuttural InOusLIlal ater Quality Monti/acing Soli Sampling/Characterization <br />IC Water System <br />II Stlf mem Rom OW kW: <br />uceese 0-57 <br />tiOC,..APHICA <br />[INTO U <br />ORMAT <br />wee SysIem Nero unmet ram Hr Fillte Nuffilld <br />VANCE NOTICUIRE, /1,1SPECTIONS <br />TiT4 7 DAT71.1_ I <br />Miv UM 24 OUR <br />STOKE <br /> <br />in <br /> <br />Pr <br />winWM= • 111•1111111111MI <br />ow <br />PAYMENT <br />RECEIVED RECEIVED <br />MAY 2 5 2011 <br />N JOAQUIN COUNTY <br />ENVIROMENTAL <br />ALTH DEPARTMENT <br />WELL/PUMP PERMIT <br />SAI4 JOACAIIN COUNTY EevuxorrelewrAL HEALTH DEPARTMENT 600 EAST Mier STREET. STOcturcur CA 95202 - 4299)499-3420 NON-REFUNDABLE PERser CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />Joe ADDRESS H•59P6 1.44//0.1 rtlet CYTYCZIP <br />CROSS STREET reeMat COJOI.Of APN :2-4:1(/ —030-06 PARcet Size ' 17 LAND Use APPWCATIOk M <br />Omaha NAME <br />°wean Aanaess 1/.596 teleh&I <br />PHONE <br />TYPE OF WURK New Wet . Replacement Well I. Well Alteration/Moddicalion Other <br />Monitoring Wed(s)-- * of wells :2 Soil Bonng(s) "cc` Cachet:finical <br />Out-O(-Serv ell : Out-Of-Service Well Renewal Grass-Connect Repair <br />New Pt „,..11(Punip eRlacemera Pump Repay • Aatse Welit asing - WELL CoNSIAuC DoN <br />Drilling Method i Mud Rotary Air Rotary _ Auger Cable Tool Push Paint J Other <br />Proposed Well Depth ft Excavation in diameter :2, Open Bottom Gravel PacirJGravel S4e <br />, Conductor Casing . in diameter I Conductor Casing Depth 9 <br />Well Casing Diarrieter. in Thickness/Gauge/TM Schad C Sleet P/estic i7; &earliest Sias/ C Other <br />Stout Seat Depth ft Neat Cement r94 lb bag15-10 gal walo U Sand Cement sack moll gal WOW Bentonite (20% solids) Other <br />CyrOut Placement Method Pumped Free Fee Other Retardant /Accelerator (name) <br />Pf0.0$7,9. Installed By Dtiller Pump Contractor D Other <br /> <br />ncrete Pedestal Dimensions: Wah _ ft Length ft Thick it 11 Christy Box Cl Stove Pipe <br />iPute ...XSu mersible ' Turbine . i Other HP Pump Sat ft Starving Water Level o. <br />i HERER CERTIF THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CEWTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LiCENSE BOARD AND THAT 1 AM IN COMPLJANCE WM.1 ALL WORKERS COMP T1051 LAWS. <br />4111011; rea Emloyee <br /> <br />Date -512....0/ <br />Data <br />A p ICre 41:2(15. q <br />DEPARTMENT USE ONLY <br />Da <br />SPECIAL Well. Permit <br />Pomp I• <br /> <br />.411 i 1S111,1%.%.- Dais Waivest Received <br />Sod Baring In •1Fon Date Constructed Well Depth 4 it COMMENTS . ,dy VA 1 I <br />- <br />PE <br />Codes <br />SC <br />Info <br />ReceivedChC ee..0141 <br />,By as _,,,, <br />Amount <br />Remitted 021/0 Permit' <br />Service Request D Invoice f . Well 1D0 <br />43:9( a.C`O '-‘,---- /110Z-tit ISI,c(i) .__45-it I ..cia--00 4,2-4,1: <br />- <br />ENO 4145 <br />IrouGu AUL MumP PERMIT <br />to <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUNCONTRACTOR <br />3.rItewt_ zzarrelek <br />mrie_ <br />2L5' <br /> • . NA: <br />fie &Le CitylSTATEIZie <br /> p.leci)699-.3g5V9 <br />crrasTATE11,oni eiA <br />N of NeriPait <br />in diameter <br />Appb,ation Accepted By <br />Grout inspection By