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WELL/PUMP PERMIT <br /> n r SVN dOAQI'LN COV%TY EMA1RONIMN-TALHEALTH DEPART:Nk1T 609 EASTS1A1!N STREET•SFOCKTONCA 95202-(.'r9P)469-3426 <br /> T NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> C2r[,lZtr r_A- <br /> 7 <br /> -4--— <br /> CROSS STREET jQL __— APV `✓ �'3�d) P:ARCF1.SIZE; g <br /> Ox_NERN.AME J� � _d CV don Chu KA Pito,E_ <br /> Z 1 <br /> OAA+ER ADDREsl _ Y Ore— CiTViSf.{TEFLIP 6, <br /> CONTRACTOR ^ EEJ9--LJ <br /> ` ( .�_C,�t-- P!}O,E_ /�� <br /> CONTRACTOR ADDRESS 1 070/�J� S • \TWLi/'ZLCtivsrATE4zAP_ �l7�S `ES L <br /> FWISCOPTRACTOR P110NE <br /> _------------. �_ 1 m <br /> SCaCD,T1L\CTOR ADDRESS C1f1lSt4iE17,IP_,___ 2 �(_ O <br /> Ll%-EMsE 0 C-571 O D-09 O Outer__ Nt m5ER E3PtRATtO,DATE 3 / 0 16 1 ^� <br /> GE0GR,APD/CAL1NFow%w:'iOM: Coordinates X — 1Toxashlp„ Range__.- Seaton—__ .—A rA p <br /> z <br /> INTENDED CASE O Do�mesdcL,PritaliO ortAgricultural Industrial C W'aterQuab!)Momming O Soil Simpline:Chanucmizarion <br /> {�uN <br /> 0 ric Water S,. __ <br /> rrdiheex ftec:O.va:. x' �Stvz:m�sro - Cccrn.Nrm.,.•P'rxc_�vu2c: �l �,:, O <br /> __ N`• 1� rr,r <br /> TAPE Or WORK ❑N0w t1':N O Raplar:�mem Well O Well Atteration?Nod+'u'cation O 1't:st Rafe ❑Other —_ -- <br /> �s:.n2c.orw,iL ramiwr.,f Fm1r^�, srmAc*oE h•�+Q: -l-: - <br /> ❑Monitoring We!Us) ❑Soil i3orirtalsl ❑GeotcehaiG:I <br /> D Well[kSrucuon O 0u!-0f-S�Tvise Wali D Out-Ot'-Scrticz Well R:.uaail <br /> \0x' O Pump Reolaccincat O Pump Re it 13 Cross-Counwion Repair <br /> WELL CONSTRLCr10., <br /> DrUbg ethod O Mud Rotary O Au Rotary 0 Auger O Cable i 001 O Puch Poim ❑Ocher_ i <br /> Proposed Weil Depth,_ fT Excm2tion in diameter O Open Bottom O Gravel Pack Gravel Sive__in diameter <br /> O Cenduetor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diant ter_ice Thickness'GaugerAST41 Scbed __ O S:cel O Plastic O 9tainles>Steil C Guar � <br /> Grout Seal Death d O Ncat Cement:9416 bag:'5.10 gal nvterl O Sind C.mzr, sack n;ir,7 eat water <br /> O Bemonite 00'S;solids) 0 Manufac^.ur-:r Spec 1!5 solids `.,> tante D Specs on File CI S.=sSubmiticd <br /> Groat PlaeeaneM Methed OPunVd O Frx Fali O Other 13 Retardant:Acc:ltxator jname)_ f <br /> PEOUT:AL 1/11141111/1 By 0 nrlltz� 0 Pump Contractor 0 Othzr_Cl Concrete Pedestal Dimensions: Widrin—A I.mo P Thick in O Christy Roz O Stme <br /> PuNiPrrersi9lc ineC30ther HP _ Pump Sct t. Statu6ngwater Le:cl II <br /> ' WELL DESTM:CTtON O Open Bosom 0 Gravel Pack 0 Untried O Other. <br /> Well ihame4r_in Totai Depth ft Depth to Wawr____f! O Ca me to t.Perforawd from A ;o ft { <br /> Slaiing>laterial 0 Neat Cement 04 lb bag:-f_IOgai carer/ 0 Sand Ccment enek rn&17 gat hater O Bentoaite Pellet; ' <br /> O Bentonite t-01-solids) D Manufacturer Spx%solids^—°o flame O Specs on Fila O Specs Submitted <br /> Placement Method O Pumped 0 Free Full O OthtT <br /> O Complete v,ith Mushroom Capfi bdow grad. O Complete in Existing S•arface Pad <br /> 1 HEREBY CEP.TUT THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILI.BE DONE 11 ACCORDANCE WITH S'.AV <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT A\D ACTIVE Y H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TEAT I AM LN COMPLIANCE WITH ALL <br /> WORIUM P.► <br /> TITLE , DATE v _/ <br /> IMENT <br /> EIVED <br /> 2017 <br /> UIN COUNTY <br /> NMENTAL <br /> EPARTMENT <br /> DEPARTME+IT USE O\LY r� <br /> t;apted By /()-q— Ara— Employee ID4 <br /> Appticetiar A I3ffie <br /> Grout Inspection By Date I El SPECIAL Well Permit <br /> a <br /> i3atc 113—It�. a WAIVERReceived <br /> P11atp 111specdon Hy— -- ' �� <br /> Destruction Inspection By -- 711*�;� Construcwd Well Depth <br /> COMMENTS <br /> PE SC Received Chedw .Anuent Permw Invoke# we"Eft <br /> Coda late By Cub Remitted <br /> q310 Q50 2�K� a <br /> EHD 43-02-006 WEB - 9'ell Ptrnat and Dec!arrrco,do,, <br /> 9,11-M07 <br />