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WELUPUMP PERMIT <br /> is"East Hazelton Avenue-$TDCRTDN CA 952g5-6232DA ISSUED <br /> SAN JoAotAN )468—U20 <br /> COUNT,EWRONMENTAL HEALTH DEPT EXPIRES 1 YEAR FROM ' <br /> CALL 209 95 -7697 FOR INSPECTIONS 22� <br /> NON-REFUNDABLE PERMIT cmyrzw <br /> NO USE APPOCATtON <br /> IOg ADDRESS PARCEL SIZE�ILA <br /> APN O -_---- ppNEw <br /> CROSS STREET __-- �i ��—f20 <br /> OWNER NAME i,/ Cr1Y1STATEILP---16 !— p- <br /> -LC/ Y PSE !J �� <br /> TOWNER ADDRESS � --_- <br /> e� <br /> (CONTRACTOR O f' z /j7(.t.. //p�j{�� CITYISTATE21P _— N <br /> CONTRACTOR ADDRESS PHONE _ N <br /> SUBCONTMCiDR _.--- C,TYISIAATErzw/_' <br /> �-=`,�SIY EXPtRATION DATE <br /> $DgCDN11tI,CTOR ADDRESS�_---�--- NUMBER SCaoi�-'- — S�GL1011...�- <br /> OUler�_ Township— <br /> a <br /> Township__ g <br /> LICENSE_ -57 Cwt o-.-----""—" Y arageniauon <br /> -;K Coordinates X _ Sod San+WngKh <br /> GEpGRAPwCAI INFORMATION. l <br /> Industrial Water Quality Morritekl9 <br /> ationlAgncuhtu « <br /> f INTENDED s DomesOdPnvay g <br /> I Public Water Systen, en+ _------ <br /> __-..---__Other____ -- •W OanrlY� <br /> tt MRere+n Mom Ownericabon <br /> nt Well YJeli AlteratiorJModHf of W,,y, GedadV>ical <br /> L_ Red s Sod Bon gt 1 I <br /> �� New Well f d wens n s �---- CrossCerleWon Repair <br /> MorAonng�1s1.— put-Ot-SenAce',011 Renewal <br /> Raiae�--`— <br /> Out-Ot-Servl-WeM <br /> Pun er+IacdnentRe air <br /> ---P-----.` <br /> New P ROwer__ <br /> Cable Toot Push Point in diatTleter <br /> W e Auger Gravel PadrlGravel Sae— <br /> Mud Rotary Ax Rotary open Bottom t�^1 <br /> Drilling Method to diameter fl <br /> Excavation�— sin Depth_--- -' (ride --- <br /> ProPo-d Well Depths —ft �a�er ! CorWuctor casing Steel Ptastic Stainless Sheet Sack mixl7 gel water <br /> Conductor Casing TM Sched__� Sand Cement____-_ <br /> Diameter 1.in ThicknesslGau9� t 94 Ib bag�-f0 gal water) {I <br /> Well C+sln9 tl Neat Cerner <br /> 1j Grout Seal OeDt---�"' Other Retardant I Accelerate(name) <br /> Bentonne(20%solids Other ��— -------- <br /> Ptrttped -Free Fall ChrlstY BoX Stove Pipe <br /> IiGrout t_pla�ernentMethod Length <br /> to flThick.�----m — -� <br /> Pump ConVacde h � <br /> L Installed BY Ions'.Width'-----n lergt _.----_ Water Level <br /> PEFt Ely7t Com"t,Pedestal Dim._ Pump Set fl Siandaq TH SAN <br /> IN ACCORDANCE YII <br /> _ Other HP K WILL BE DONET REQUIRED LICENSE IS <br /> Subrnerslble ire AT THE WOR CERTIFY THAALL <br /> P _ I PESO <br /> OEREB COUNTY ERT( ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. <br /> CTORS STATE LICENSE BOARD ANO THAT I AM IN COMPLIANCE WITH <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND TH <br /> TRA <br /> 1 PEGTION ` <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA COIN gpVANCE NOTICE REQUIRED F TE <br /> WORKERS COMPENSATION LAN S.U .4 H <br /> TrTLE <br /> StpNED <br /> F <br /> D <br /> L <br /> NTY <br /> L <br /> ' FNT <br /> T U E NLY <br /> D p A TME Employee It1:0 <br /> Area__----- <br /> Data /1 SPECIAL We11 POrMit <br /> � Accepted By Date—__ WAIVER Rece1V8d <br /> � ft <br /> Grout Inspection B _ Date th <br /> Constructed We11 Dep <br /> Puntp iny /S. <br /> Sw Bo"1 echos By N i•-v''- Well IOi <br /> COMMENTS ���,[.� 'armW Mvolce• <br /> rAnwunt Date Service Re uestk <br /> k!J <br /> PE Sc Received Ch Remltted� /��5 — <br /> Gooss Into <br /> WEl t)PUMP PERw <br />