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WELL/PUMP PERMIT <br /> SANJOAOVIN Counav ENVIRONMENTAL HEALTH DEPARTMEW 304EWEBERAVE3"FL-SmKTONCA95202-(209)Y68-3420 <br /> NON-REFUNDABLE <br /> PERMIT <br /> �/s(�/ CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRPJO r�✓r/`� S 11 L L ' Cm21P <br /> a <br /> /C/ ,• APN XIT3-120-35 PARCEL SIZE '-F•06 ¢G <br /> OWNER NAME ��'J1Gj( N/// PROONNEE�AtSL -9/S-97Yd <br /> OWNERADDR �_/ � &/Id J/CfrtV/STATEIGP <br /> CONIYUCTOR / PHON <br /> MADO!, <br /> COMCTOR ADD EEB / CITY/STATOZIP 1e <br /> SUaCOelciLaCTOR PIIONE <br /> StIWOMMCTORADDRFSS / /'T. —C�mJ/STATE/LIP <br /> LICENSE ❑C-57 0 C-61 If D-09 R G/0 J/r- NUMIER N E%PIMTON DATE <br /> GEOOMPMICALINPORMATION: Cusselnat. X Y Tawnehlp Range_ Section_ <br /> INeeXDED USE rnaie/Pdvate O InigatioNAgricuWnl ❑Industrial O Wear Quality Monitoring O Soil Samplit"Cheracterivdon <br /> 0 Public Waters yyssl1c�nn <br /> Irdwe s rm . uN yK.m eme Co.. m ^r <br /> TYPEOSWORK ❑New Wall OIt'lacear nt Well O Well Altmtion/Modi6auon El Tat Hole E3Owm <br /> ❑Moniwring Well(a)_ x"rena"m I7Soil Bono&(¢)_ wmEeorhudnp OGeot.hniul m.Reorbeirp <br /> 0 WNI Destruction ElOut- F-Ssrma Well 0Oul-0f-Service Wall R.10 New Pum D Punnp Ec,,Iaentevt )&Punp Repair 0 Call-Curnection R it <br /> WELLCONSTRUCDON <br /> Drilling Method ❑Mud Roary D Air Roary ❑Auger 0 Cable Tool 0 Punh Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Run. ❑Gravel Peek/Gravel Sim in diameter a ' <br /> O Corducmr Casing in diameter / Condumm Cuing Depth ft <br /> Well Cuing Diamcler_in Thickness/GaugdASTM Sched 0 Steel 0 Pleeuc ❑Sand.Steel 0 Odwr <br /> Grout Seal Dcpw R ❑Nat Cemat(941A bo,,15-10ged rarer) []Sand Cem.t xud ma 17 fill Water <br /> O B.wnite(2Wo solids) OManu6clurer Spa%wIids_% Name ❑Season File OSpea SubmilW O <br /> Grout Plaeemenl Method OPumped ❑Ft.Fall 0Other ORNaMant/Aaekrater(name) <br /> PEDESTAL Installed By ❑Driller 12 Pump Contractor E3Other <br /> 0 Consist,Pedaal Dimemiona: Width a Ievgdt ft Thick in 0 Christy Bos 0 Stoves pip <br /> Pump �86ubmmsible OTurbine I70we! HP Pump Set Slendivg Water Level fl <br /> WELL DTSTNUCDON 0 Open Bosom 0 Gravel Pack If UsMaeed 0 Otho y. <br /> Wrll Diameter_in Toal Depth ft Depth to Water ft 0 Cuing m be Peal rstedi firm_ft M_fl (� <br /> Sealing Material ❑Nat Cement(94 11,ho,,/5-l0 Sul nvser) 0 Sand Cament rm*ma/7 Ed war Cl Bsmm.ite Pellets -41 <br /> Cl Benwnite(20%solids) OManuacturtr Spec%solids_% Nsme OSpaaon Filr OSpecs Submitted <br /> Pacemevt Methal O Pumped 0 I.Fall 0 Ower V` <br /> 0 Complete with Mushroom Cep ft below grade 0 Complete to Existing Surface Pad <br /> C <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND LAT THE WORK WILL IF DONE IN ACCORDANCE LWITHICENSE <br /> SAN l5 <br /> J,CURRENT <br /> COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED W WITH A IS <br /> ,CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN TION <br /> IMUM 14 HOUR ADVANCE NOTICEE RE UIRED FOR INSPECTIONS /` <br /> SIGNED TRLI DATE.22q QJ <br /> N <br /> T <br /> D <br /> WENT <br /> NTY <br /> (. <br /> DEPARTMENT US 710 5� <br /> Appliadon AccWad By mt. 3 fdS Arta Z'[�' Employ.1Dk54 49 <br /> Gmminapation By 0.a sa ❑ SPECIAL WI!11 Per mit <br /> Pump Inspection By y� Data�n-f3�9SdJ ❑ WAIVER Received <br /> Deswcsion b spalion By / Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Amouot Ch. R.Nved Date PermW Imiale Well 101 <br /> Codes Info Rankled uh By Servk.R vutg <br /> Y3.4T-I OSO SO-OO f7 3 Q6— <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 5n2002 <br />