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W biLL/ Pum?m? Yl•kLileli l qtr 1, <br /> &AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErAwrmEwr 304 E WEDER AVE 3'a FL-S TN ON CA 95m-(289)469,M9 <br /> NON-REFUNDABLE PERMIT CALL 2191 953-7697 rOR IN& ECUIONs(/ EXPIRES I YEAR FROM DATlEE ISSUED <br /> JODADDRESS 5D &-• e— cr1YfLIP rt]�� �+ g <br /> cRt>$s STREET APN PARCEL SITE <br /> OWNER NAME JJ�^1 / PHONE d5�--1Z <br /> OwNERADDRESS -V e 4467_,­� CiTY/SrATEMP <br /> CONTRACTOR 4PlF/l ,jIi L PHONE <br /> CtNfRALIMAispRgg9 .h�ien6- 57 7 CtTvlsrATFJZIP e <br /> SUBCONTRACTOR ADDRESS Crrv/SrATVZJP <br /> LICENSE C3 C-57 Q C-61 D D-09 D Other NUMBER ExPINATNIN DATE <br /> GEOGRAPHICAL INFORMATION: Ceerdiasle X Y Township L Range=�swoon Il <br /> `r <br /> INTENDED USE O DonlesticIPAvue (3 IrrigsligJAgricultural C]lndustriol 17 water Quality MonitoringSal SamplinyClarrcttri>stia,I I <br /> O Public Wats S� <br /> If ditTaant flanwawsyswmNew uNrrr tl p r � <br /> TYPEOF WONK O New Well 13 Replacmmt Well O Well Alterstion/Modiltalion D Tett Hale D Other <br /> O Monitoring Wella) nutlbrrof-Wit t-�a -11 Boring(s) ""nbngfh0"'ar aOeolechnical orh01A1� <br /> D Well Destruction O Out-Of-Service Well O Out-0f-Service Well Renewal <br /> O New Pump 13 Puny Replacement O Pump Repair O Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Metbed O Mud Knotty 0 Air Rotary O Auger Cl Cable Tool 13 Push Point �Pher <br /> Proposed Well Depth ;!:� ft Excavation in diameter C)Open Bottom O Gravel Pack/Grovel Sim in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft { <br /> Well Casing Diameter_in Thickftess/GaugdASTM Schad D Steel D Plastic O Stsinlea Steel E)Other <br /> Grent Seal Depth ft O Nest Cement(941h hug/J-10 gal uvrrer) O Sand Cement oat rN(r/7 gal water <br /> O Bentonite(20%solids) O Manufacturer Spec%solids % Name D Specs on Fik E3 Spca Submitted <br /> Grand Placement Method D Pumped 17 Free Fall 13 Other D Retardant/Accelerator(name) <br /> PEDESTAL IR"Ikd By 13 Driller R Pump Contractor O Other <br /> D Ceatmie Pedestal Dimensions: Width It Length R Thick. . in D ChrMy Box 0 Store Pip <br /> Pump O Subno.b1c D Turbine 13 Odra HP Pump Set fl Standing Water Level fl <br /> WEIR.DEFTRUffm D Open Bottom 0 Gravel Pack D Uncaaed E3 Other <br /> Well Diameter in Total Depth ft Depth to Water ft D Cuing to be Perturned from fl to fl <br /> Sealing Mnt"W )keW Cement IN 1h&W15-10 gut row ) D Sud Cement suet rix 17 gal water D Bentonite Pellets <br /> D Bentonite(M solids) O Mmulhcmra Spec%solids_% Name D Specsou File M Spec SuMatod <br /> Placement Method D Pumped Foil OOther <br /> 13 Complete with Mushroom fl below Vade D Complete to Existing Surface Pad <br /> 1 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 LICENSL IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRE1)FOR INSPECTIONS <br /> 31GNED TnLz <br /> DATE <br /> I IF <br /> jiI FiVako -Z Ins <br /> a SUI 4 U <br /> DEPARTMENT USE <br /> ApplicsfiorwAcoeptedBy'-711 t Date 3 <br /> Ares Employee iChl' <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Destruction Inspection By Efate Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Amount Check#/ Reedved Dare Parm)U <br /> Cede nfo Remitted Crab By.I Service Reauesto Invoke# wen ID# <br /> 3 <br /> EHD 47-02 006 snlm /T ( MASTER WATER WELL PERMIT <br /> a.. <br />