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• WELUPU►MP PERNT <br /> SAN JO,AQUIN COUNTY ENVIRONMENTAL I-IEALTI-I DEPT 9868 East Hazelton Avenue-STOCI<TON CA 95205-6232 - (209)468-3420 <br /> NL)N-REFUNDABLE PERMIT +r^ CALF 2009 953-7697 FOR INSPECT IONS ���(J EXPIRES `I YEAR FROM DATE VSSUED <br /> .iOG ti(DDRESS <br /> ` (¢� SOIL�Qtr f CITY/ZIP- lL,�O�ti /5�IP6 M <br /> C p <br /> (:ROSS STREET Wt-10t- 'Ri IID0-1 RI APN-245-7-21b— A _PARCEL SIZE LAND USE APPLICATION# m <br /> Cn <br /> — � /Mohler��IJ�/ �a wls LP PHONE 43_ -V t, <br /> CwiIL"R(IAIIE 7/ <br /> OWNER:'.DDRESS (, <br /> 1.Z .§S• ti/,e7r CIT(/STATE/ZIP f? P&" _6?Ls <br /> CONTIZACTOR MA � f(,� � [�I btl! PHONE_y 72 9;2P <br /> ,,�J <br /> GON-i RAC T OR ADDRESS� �� off/�Q, -r P� CITY/STATE/�IP�Q��_� r <br /> SUBCONTRACTOR PHONE <br /> SU SCONTRACTOR:ADDRESS CIT(ISTA T E/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPI-IICF.L INPORM,ATION: COOI'ClinatOS:C " Township Ranee Section <br /> N OR <br /> INTENDED IASE ❑ Domestic/Private Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water 6ystem Name Contact Name or Phone Number <br /> YIORI X►I�lew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> r � 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) It of borings ❑ Geotechnical It of borings <br /> n �• 0 Out-0f Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair M <br /> 0 New PUI-n D 0 Purnp Replacement 0 PUmp Repair 0 Raise Well Casingl J <br /> c TRucnoN <br /> QI <br /> g .,Qod KMud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> 3 'lell Depth R— fi L=xcavaiion 1Z in diameter ❑ Open Bottom P<Gravel Pack/Gravel Size in diame r <br /> �� 0 Conductor Casing in diameter / Conductor Casing Depth ft :4 <br /> g Diameter in Thickness/Gauge/ASTM Sched ❑ Steel {Plastic ❑ Stainless Steel 0 Other <br /> Wi Depth lea ft ❑ Neat Cement(94/b bag/540 gal wate/) ❑ Sand Cement sack mix/7 gal wate <br /> ABentoniic(20%solids) ❑ Other <br /> Grout Placement Method PQurnped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PIHDESTP"L Installed By ❑ Driller ❑ Punp Contractor D Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Bou ❑ Stove Pipe <br /> S:�uMP D Submersible❑ Turbine ❑ Other 1-IP Pump Set ft -Standing Water Level ft <br /> I HEI EDY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUlN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY TI-IA71 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> �/�� Q <br /> SIGNED �Lct ►r'1 TITLE 91t16 DATE <br /> I <br /> i 20a <br /> ---- SANJOAU N O N <br /> 01�Ta <br /> 7.P <br /> .-- M ENT U E /N LY <br /> Application Accepted By Date� �?/ l Area—1 Employee IDIAv'"�"" /7 <br /> Grout Inspection By_ Date. C SPE IAL a6 O11 Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth i <br /> COMMENTS O <br /> PE SC Received ChecltV Amount Permit/ <br /> Codes Info By Caph Remitted `e Service Reoluest;h In Well ID;i <br /> LA) JL Vill I <br /> RF <br /> EI-ID 43-06 WELL/PUMP PERMIT <br /> u/04/CII <br />