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/201 <br />4 <br />7 23:03 FAX 4156427055 CANON U001/002 <br />Rx P is <br />WELL/PUMP PERMIT 7/2-1? / 7 <br />SAN JdACUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTdN AVENUE - SYacKToN CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT GALL ("LU9) 953.7697 FOR INSPECTIONS LAPIRE5 7 YEAR FROM DATE ISSUED <br />Joe AD13RESS Gtievr-tn"6aATc\ z2Ts8 5. Xc-;.sS j\ 91 CITY.,, 766,c� CA <br />CROSS STREET Weyroj-T-� APN a3T�T- oby- 1 �l PARCEL SIZE I1�ILLANO UEEAPPLICATION#�T <br />OWNER NAME��,a O(, / '/'LX L'u• 7 cJG:11 ic.t.'t)iu�^PHONE S�� �° A �j <br />OWNER ADDRESS C-keVi Q?N �� IQo . 3;c1<4 -0e^ t nv1STATEMP-. t �d��l-/'J^l/�)�7t <br />CONTRACTOR ��111 'T('1' rn tt> i�-�j —� ('PHONE �fY^I�- /-74 �/ <br />CONTRACTOR ADDRESS 2 vel , e- f,� CITY/STATEIZIP J(�+\ { �j�G-t.j [4°J„ �� %t yl� <br />LI <br />SU@CONTRACTQR 6-51< ]/�q� J^ PHO�NIfE C�� -C�/y7 .r!/�/�/` <br />SUBCONTRACTOR ADDRESS / `� �/ >` � � :� � CIPr/STATE(ZIP 1 /� "��� 7350 <br />LICENSE r. -C-53> 1111ICS1 IIID -09 ■Other NUMBER r EXPIRATION DATE 12 <br />INTENDED USE PDomestic/Piivale w inigation/AgricURUral M Industrial 0 Water Quality Monitoring 11 Sampling/Charactevation <br />.Public Water System <br />ldiffaronl}mm Owner, WalersynR- ame Cooled Nameor h. -Num r <br />Co <br />m <br />D <br />v <br />0 <br />M <br />N <br />to <br />TYPE OF WORK Will . M Replacement Well ■Well Alteration/Modification ■Other C <br />Adonitodng Well(s) - #of wells mSoil Boring(s) #ornarlres eGe4technical _ _#atnodngs <br />opupOf-Service Well ■Out-OfService Well Renewal ECross-Connection Repair <br />N New Pump ■Pump Replacement =Pump Repair '•Raise Well Casing <br />WELL UONSrRUCTION j�►, <br />Drilling Method �,IUd Rotary WAir Rotary MAuger �a Tool Oush Point � Other <br />�'2 S/[ <br />Proposed Well Depth ,9r5ft Excavation In diameter MOpen Bottom e6ravet PacklGravel Size in diameter <br />■Conductor Casing In diameter / Conductor Casing Depth ft <br />Well CasingDiameter_ n ThlOknes auge/ASTM Sched ESteel NPlastic NStainless Steel Mpther <br />Grout Seal Depth ft Feat Cement (941b baglS•10 gal water) Sand Cement _ sack mix/7 gal water <br />I�entnni (2q°/a so)ids) Other e � <br />Grout Placement Method humped MFreeFall ther �r`MI"\i� =Retardant/ Accelerator (name) <br />PEDESTAL Installed By driller I11Pump Contractor z Other <br />PGQncrete Pedestal Npimensions; Width ft Length ft Thick In IrChrlsty Bon W SLOVE Pipe <br />PUMP e6ubmersible fiurbine MOther HP Pump Set ft Standing Water Levei It <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- 1 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 />p\.�1d - E,1f <br />,� PATRICK MORRISON <br />Professional Geologist - P.G. #7174 <br />C Certrfted Engineering Geologist - C.E.G. #/2643 <br />t \9 Vice President <br />�kANC' <br />SMITH -EMERY SAN FRANCISCO <br />1940 OAKDALE AVENUE <br />SAN FRANCISCO, CALIFORNIA 94124 <br />(415) 542-SECO(7326) - FAX (415) 642-7055 <br />E -Mail: pmarrison@8milhemerysf.com <br />Web Site: hfrp:llwwvv.smithemerysf.com <br />TESTING • INSPECTION • ENGINEERS - GEOTECH - CHEMISTS <br />4fyRFL`F � �r <br />✓p4 <br />R Qt/ <br />N <br />,4t'hr <br />Q?r <br />kEhr <br />.DEPARTMENT USE ONLY�f, <br />Application Accepted By Date rV z , / Araa �.1 ` Employee ID# h # t �'"r d <br />GrVUI Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date // WAIVER Received % <br />Sol] Boring In9^pectlon By - J Date l! Constructed Well Depth ft <br />/ <br />COMMENTS !.L;A�H I OL ('. !1 11101 r.,!n nI' ri'J ,171 n.,( Ii' r( .. 1 <br />PE <br />Codas <br />SC Received Check#/ <br />Info B Cash <br />Amount <br />Remitted <br />Date Permid Invoice 0 Well ID# <br />Service Request a <br />put <br />Received Time Sep , 2 8. 2017 11;15 A M No -2374 W8-1-1PUMP PERMIT <br />jmg <br />