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WELL/PUMP PERMIT <br /> SAN1e� V FD� <br /> � SOApNNCOUNIY ENVDtONMGYPALH DmARrtdexr .RIdE WlBERAVLJ®FL- CKTONCA95202 J12 <br /> NON-REFUNDABLE PERMIT CALL 09 9a`3-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE s <br /> JOBADDRESS /y000 E. CHyfzw Lechford,(2A 9sJ�ES 11 <br /> 2005 <br /> CaOSS S'rteeeE APIA PARCGLSrze LAND Use AtvucAnonp <br /> Owm+ERNAMe Tuna- oil Con, PRONezo�-�€s-f 1 THEALTH <br /> OWNF,RADDaeSS (4000 E. Higyw 'V P CITY/STATVLW L.-oekref'Ord .cA9�910IT ERVICES <br /> CONIRACIOR Pro-mi' tJ¢r'UicaLlnC. (34,-* .37923EL) Pao3e SZO Sy$-OZklB <br /> C0NrRAcroRAOOR.se375S N .l3UsinQ.rsCllrt-ler Dr, CITY/STATMM—FuCSOn A2. 8570S <br /> SOBCoNT OR N/A FRONL <br /> SUBCONTRACLOR ADDRESS CITYWA1 11? <br /> CA -rADK <br /> LICMSE Cl C-57 Cl C-61 Cl D-09 Otho TESTER 61C. NUHneR b j- 'c' EXNaenoN DATE I dGID 'r-4N <br /> GE.00.RAPIRCALINmRMATION: Coordmabs X Y Toveremp_ Range_ Sectlan <br /> INrwIFm USE O Domestic/Pnvate 0 Inigation/AgncWoval 0 Industrial O Water Quality Monitoring O Soil Sampling/ChamctedEstion <br /> 0 Public Well System <br /> UdD'aeahan Own . eusyeas uu .,ww as m <br /> TYPEOFWoRa ONes,Wall OReplacementWall OWall AlteratiaJModificetim 13 Test Hole Other 8LD T <br /> Cl Monitoring Well(.) dofwells 0Soil Boring(.) edbon® OGeetechsucal p0r <br /> O Well Destratim D Om-0f-Service Well D Ou[-0GSemce Well Renewal <br /> ClNae,Puap 0 Par,R lacemerd O Pong,%spsix 0Cnes-Connection <br /> WELLCONSfRICfION r/ /__/ <br /> DrlBiag Method 0Mad Rotary Cl Air Rotary Cl Auger Cl Cable Tool Opast,Point )(ba.,&L ELD Work Gltxn t(ritT'D((,( <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom Cl Gravel Pack/Gravel Size in diameter <br /> OConductm Casing indiameter / Conductor Casing Depth ft <br /> Well Ca Ong Diameter in Tleicknexs/Gauge'ASPM Schad O Steel Cl Plastic O Staildes Steel D Otter <br /> Grout Seal Depth ft ONeat Cereent(94lbhc,15-f0ga/wam1) OSand Cement vackmly/7ge1 water <br /> 0 Bentmdte(20%solids) 0 Manuthchua Spa%solids % Name 0 Specs on File 0 Specs Sabmitted <br /> Grout Placement Melhod 0 Pumped 0 Free Fall 0 Other Cl Retardant/Accelerator(name) <br /> PETMTS. Installed By ODrilla 13 Pinup Condiment DOther <br /> 0 Cesarean,Pedestal DhswvebvR Width_ft Length ft TM k in 0 Cbddy Bos 0 Store Pipe <br /> Ptm- Cl Submersible 0 Turbine 0 OtherHP Pump Setft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIPOWYIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Mi NI=ICTf 2J HOUR ADVANCE NOTICE LU,QLIRED FOR INJSPECTIONS <br /> SIGNED TME /'d 00GIA&� DATE <br /> P <br /> (1 I� DEPARTMENT USE ONLY <br /> Application Accepted By—D- I hd.U) Date 'L%(�D<i Arse Employ.IDN <br /> Groh les x,.fim By Date E3 SPECIAL Well Permit <br /> Pinup Inspection By Dow 0 WAIVER Received <br /> Destruction Btspoetion By Data Covttmcled Well Depth R <br /> COMMENTS <br /> PE SC Received Ch.W Arsonist Date PermW Imelcep Wo11IDp <br /> Codes Imo B Resolved Server veep <br /> /30033 L o 5 <br /> Eul uos.ms wELLruRyyer•.' <br /> let, <br />