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!un 16 16 10:20a Ken Gross Wells& Pumps 2097458584 �„ p,3 <br /> ' r, WELUPUMP PERMIT <br /> 'SANJDAQLfIN COUtiTY ENVIRONMENTAL HEALTH DEPARTkENT IE'6a EASTHAIELTON AVENUE-SrocKr"CA 95205 •(209)468-U20 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AoDR>_ss <br /> _ p <br /> CRDSS STREEr\)11r. ." � APN 4_._ ARLELSRE_-G113 LAND 115E APPLIC T10N AI m <br /> ONJNERNAMEZa <br /> `� _L, j,/" VDI_..,_" Z�-3� PHONE ✓/ � <br /> OWNERADORESS r I L_ __. �;ITYfSTATE21PdIn <br /> C <br /> CONTRACTOR - �� y� �1..� f __.,rVic-e1� L PHONF_ J U S <br /> CONTRACTOR ADDRESS � �--I/ ,C -� ` V LT CnYISTATFOP <br /> Si4CON777ACTOR _ ._-.__ \J _.. .--_ PHONE _- - <br /> SUSCONTRACTOR/ALI)RESS <br /> "EfJSE 11'L-S7 rl C61 7 D-09 :I Other _ N'-vAsER E.xnuirtoiDATE �_ r <br /> GEOGRAPNICALINFCIRNAMON: Coordinates Y Township_ Range SeCtio:.___ <br /> INTEnDEDVL E &6omeslkidlorivate C InigationlAgria!ltural O Industrial O VVaterQuaPyMonitorIng 7 So7Sampliing/Char9ctettzatiun <br /> U Public Water Sy ni .- ---- — <br /> ift➢nerent1—Own r. - Ter M ame4tad 146mber oe r <br /> TYi E OF WORK p"(Vew Well Realacemenl Weil C'Nell Alle alionNbdificadon G Other_ <br /> n Monitoring Well(s) Aof wells r Soil boring(s) ae}b0f1rKp rT Ge otechni©I oaf borings <br /> O Out-Of-Service Well C Out-Of Service Well Renewal J Cmss-Ccnnacton RepaTr <br /> p!aew PumO 3 Pump Replacement C Pump Repair 7 Rase Well Casing <br /> WELLCOMMUCTION <br /> Drilling Method O Mudry 7 Air Rotary -Auger ✓1, able Tod G Push Point C Other _— <br /> Proposed Well Depth Ro �� ft Excavation JV in diameter � *Open Bottom 7 Gravel Pa::k/Gravet Size in diameter <br /> O Cond=or Casing in dtameler / ConductorJCasing Oepth _ft <br /> Well Casing Diameter (-in TN knessrGeuge/ASTM Sched / 5 I Steel -i Plastic rl Stainless Steel rl Other <br /> Grant Seal Depth ZXQ ft O Neat Cement(94 lb bag/--10 gat water) Sand Cement /�f r Sark rnbJ gal water <br /> LI Bentonite(20%solids) O Other <br /> Grout Placement Method a Pumped ::Free Fall i(Other IkVXr-W RefaNantlAccelerator(name) <br /> PEDESTAL Installed Byp!Sn�ler l PumpConUador r Other <br /> u !t Concrete Pedestal rDlmensions:WEdth 7 fI Len g3h It Thick <br /> _ in l Christy Box -I Stove Pipe <br /> PUMP - utomersibI.C.Turbine D Other HP Pump Set ft Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WERK WILL BE DONE IN ACCORDANCE WITH SAN1`U <br /> JAQUIN 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 /> MINIMUM 24 HOUR ICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 5! <br /> SIONm TYT1.E DATE <br /> t <br /> law <br /> ENVI, M T41 19— <br /> — - ENT <br /> ' IVED <br /> T I- <br /> a N 2016 <br /> COUNTY <br /> ENTAL <br /> -I PA T M E N T S E N L Y /Y•��V/�' HEALTT�H(/D/EPPA DEPARTMENT <br /> Applicabo�n Amepted Date Z Area_ Employee IDA Ste^ 11.Y <br /> Grout Inspection By Dale t Ci SPECIAL Well PeTrnit <br /> Pump InspeCIiDn By Dale C WA1vER Refer<ed <br /> Sol Boring Inspection By.. Dale Constructed Well Depth ft <br /> E C%�T Lri` �� ���• �r�/�',11��Q�Cnl�i �'�"' =-�'�i �-�/G: <br /> i� <br /> PE SC Received Checm Arnotmt Date Permit/ Involceg Well low <br /> Codes Info B Cash Rernit7ed Service Request# <br /> 1 l �/ 27/I1, 99-00-15 1 a2- <br /> 0 lP 3 <br /> —w MqGvQtD<1� W8-L/PLIiP PERirr <br /> Received Time Jun. 16. 2016 10: 36AM No, 0000 9-?-7A-4 <br />