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Ow** <br />mt. Wen Permit <br />ANER Received <br />Application A <br />Grout I <br />Pump It <br />Constructed Well Depth <br />Q5 644 <br />6'0,i Boring Lis- <br />COMMENTS <br />YMENT <br />CEIVED <br />0 4 2 0 19 <br />UIN COUNTY <br />RON MENTAL rH DEPARTMENT <br />WELL/PUMP PERMIT <br />JOAWS+ COUNTY ENvIRONeltarsi. HUM DePARmitirr 1558 EAST NIZELTON AVER1Je -STOCXTOW CA952 5 4 209) eliFI-3120 <br />NON-REFUNDABLE PERNITT www.skipv.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />1JOB ADDRESS E hcxr c. (-) cis 2-2-0 <br />eda <br />ROSS STREETTA1-1 R APNCO-7-4.11)C - /pi-. PARCEL SIZE LAND USE APPLICATION PP <br />CA*(Ell Nue C., (N Tv \ 'IN Vtivf; I /34(.0 po+em 2.0 c1 yr( t›.7 <br />OWNZA ADIMEISS !PO LI 0 <br />CosTwAcrow r\A D*40 \- .T;) <br />CONTRACTOR AODRESS q CITY/STATE/ZIP OG,,,t9 Pi, /4) CA, <br /> <br />;SeticoiirraACrow/Coasuccurr PHONI <br />iStISODIeTRACTOR+COmSuLTART ADDRESS <br /> <br />CrryiaTATFJZr <br />',Amu, 1"ri ExpIRATiOit ell <br /> <br />LtWt8# NV C-57 C41 0-09 <br />Seller+ PARTY: OWRESI <br /> <br />34311CONTRACT0R/C0NSU4.TANT <br /> <br />DOMEarriC WELL SAMPLING: Gemini Mineral/Conform Bacteria (4391) Dinrornoclaoropropene (4392) n Arsenic (4393) <br />Iirtiroapift DariesticdPTNININ/ Inioetion+Agricul(urel Incluselm Water aaelity Morino:lag Soli Samp-ficorChsrecteraation <br />,Pu0II Vvate( System <br />&tow,: *on Own., WAN *Awn P.M4 Comsat ram* or Oho* swore+ <br />TrPt OF WORA-s-V Neve Well Replacement Well Well AtterationfMcatcabon Olner <br />Mcneoring Welt) tt of wells Soil Eionnig(e) 134 itenrce Geotchntcai I or wines <br /> <br />. Oub-Cf-Seivice Wen Out-Oi-Service Wee Renewal Cross-Connection Repair <br />New Pump Pump Pa 031.1 Pump Repair Rates Welt Css <br />!fti1iirt2SEISIE.E20. <br />1D/filing Method .1". Mud Rotary A tr Rotary "II Auger N'ti Cable Toot Push Point .1. Other <br />IPT0P0se4 WIRI Depth 600 ft k ixotwation in aiarnalat Open Bottom Cirsvei Pecic/Gravel Size <br />Canducy,,Cardcp -2-Tur in diameter I Conductor CseckDspin 5 ft <br />Weil Casing Cisme* I CtA in ThIcknaes/GaugefASTM Scheel :2=5 (7 Ste Ph Stoles eeli. Other <br />Grout Seal 0 It Neat Cement (94 /b baiy5-10 bye ...44) -NPSand Cement <br />el oto I.; siSt„,: <br />10- .=> sack mix17 gal water <br />Bentonite (20% goads) Octet <br />Method P, ell Other Retardant <br /> <br />losteRed By Draw Pump <br />Concrete Pedestal ...1Dirnsnelons: <br />Diner <br />LINth <br /> <br />ft Truck C SC‘x Stove KOS <br /> <br />Submatralbien Turbine OINK HP Pump Sat <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Sic.stO <br />4411 licitA2 A E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Tine C.6-"? Dare / 1 <br />Ole <br />PE <br />Codes <br />SC <br />lnfo <br />ROCAtivet1 I Checicti/ IAmount <br />C4s h,,--- - - 'RemItted <br />Perm <br />Service R <br />Invoice S Visli 1434, <br />7iiii 4/4 Aii <br />-11 <br />._......._. I <br />Ent'. 4.i.08 .titoI WELL fl.tiMP FFewn. <br />cirds...mp 4 cqmf 0 Cr\ 752.2_d <br />53<3 -7 3