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i <br /> - - _ WELL I PUMP PERMIT EeeanYti3' J . SrocKTc)-4CA95202-(209)467!-3420 <br /> CYAN JOAQUIN COl7NTY ENVIRONMLNTAL..,L'I'n DEPARTMENT <br /> NONFFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ E <br /> FADVAESS `n <br /> r` -10 11 C CITYlZtl' u <br /> PARC£1.SIZE W�'d LAND USE APPLICATION p ] <br /> Er LYAPN ' � (<j -7RZCIfPtiaNE E CITYISTATTI'LIPDRESS {t ' <br /> k\,\ 1`l PHONE <br /> CONTRACTORII <br /> t7A <br /> CITYISTATEIZIP <br /> CONTRACTOR ADDRESS <br /> PHONE <br /> St;OCONTRACTOR <br /> C1TYl5TATE17AP <br /> SUBCONTRACTOR ADDRENS <br /> EXPIRATION DATE <br /> LICENSE 'V C-57 D C-61 (3 Mg d Other <br /> NUMBER +� <br /> Y Township_ Rangr Section— <br /> GEOORAPI11CA1.INPDRMATION; CoardlsateS % <br /> INTENDEDUSE -9D0mesne1PnVele DIrrigationAgricultural ❑Industrial Cl Water Qua]I. Monitoring DSoilSamplinglCharacteriaation <br /> [2 Public Water System n yncm.art+r nmxr amcw one u cr <br /> If diRcrenl It. Owner. °1 <br /> TYP£OF WORK ew Well XReplacenwrt Well D Well Alterj%ion:'Modiftcation Or Tet Halt D Other r oT6a ngs <br /> ! <br /> C:Monitoring Wells) k Of Wclis O Soil Boring(s) of C]Geotechnical <br /> ❑Well Destruction ❑Out-Of-service Well Cl Out-Of-Service Well Renewal <br /> 17 New Pum D'amp ❑Cross-Connection Repair <br /> WEt.L CONSTRDLTION <br /> Drilling MNhtld Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑push point t cr <br /> Gravel Peck I Gravel Size in diameter <br /> proposed Well Depth L�C� R Excavation 1-1," . in diametaT ❑Open Bottom R <br /> D Conductor Casing in diameter I Conductor Casing Depth_� _- (11 <br /> ❑Stccl .$Plastic ❑Stainless Steel ❑Other <br /> Welt Caring Diameter in Thickness/Gauge/ASTM Schcd I L,O - yac,(mix 7 7 I water <br /> Grout Sett) Depth R D Neat Cement(p4!h hug!5-10 gal wurvrJ ❑Sand Cement S? <br /> �8cntonite(20%solids) D Manufacturer Spec%solids_% Name lett t; .=' D Specs on File ❑Specs Submitted <br /> Grout Placement Method 'fy('Pumped 0 Free Fall ❑Otho ❑Reta am r Acceiera[br{namr) <br /> PEDESTAL Installed B ❑Driller D Pump Contractor ❑Other <br /> in ❑ <br /> ❑Concrete Pedestal Dimensions: Widthh Length-fl: Thick Cy'Box D Stove Pipe <br /> pLiMp ❑Submcmitic 11 Turbine 13 Other _ kiP Pump Set R Standing Water Level R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I ALSO CERTIFY THAT MY REQUIRED E IS <br /> 0 RENT AND AC ORDINANCES, <br /> WITH THE CALIFORNIA S <br /> CONTRACTOR TATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. f1 <br /> MINIMUM 24 FLOUR ADVANCE NOTICE REQUIRED ICOR INSPECTIONS <br /> S[cN£D <br /> ��_ Trrix Q r-Alt r DATE <br /> -- b <br /> - t <br /> D <br /> X <br /> A <br /> F } EAR <br /> a <br /> � 1 <br /> 1 � <br /> 4?I�r� '•' - • " ' '�' /�_ DEPART III E N T USE ONLY <br /> �• Date ti 2) w Area Employee 1111 <br /> Application Accepred Ry :.^ <br /> p SPECIAL Well Permit <br /> Oaw <br /> Gnuul Inspection By • . � W R - L <br /> +.41' is. Pump inspection By — r - a- Daie - �_. ---..❑-,..•,.,:kI,YER; eteiv <br /> - - - _ Date ;,,.,,,- Constructed Well Depth <br /> _ Desmc ien inspection By <br /> COMMENTS <br /> r <br /> yPE SCReceived Checkifl x Amount Dale Permit! InvolceN Well ID# <br /> Codca Info B Remitted Nervice Re urat p <br /> �f3 71; I 910 I vs SRC, <br /> W e:Ll.4iIMP PERMIT <br /> ENO 0-0i-0 <br /> xaro. <br />