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WELL/ PUMP PERMIT { <br /> SW JOAQUIN COUNTY ENVIRONMENTAL HEALTR DEPARTMLVT 30.1 E WESER AVE 3-FL-STOtDTON CA 95202 -(209)4W3420 <br /> NON-REPUNDABLE PERMIT <br /> CALL. 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOSADORESS •�`� v E• C !� - Cml7ir y <br /> CIIOSA STVEET NZ�U�/r�R�_. / �y(� l APN C S!- 1 r t'-Iv/ PARCCL 517E LAND USE APPLACJATIOM <br /> OWNER NAMC _` &i I A(„�/+r il` PHONE <br /> OWNER ADUPMV, _ ` CITYISTATVZIP <br /> CONTRACTOR �Q ) r �/� PHONE <br /> CON17tACTOR AD0U.S,, / Crrr/STATr/ZO, <br /> SUSUOK17RACTOR PHONE _ <br /> 6WCOKrYACTOR ADDttm_ CrrVMTATE/ZIP <br /> Ulcm 4E ,jib-s7 ❑C-61 13 D-09 0 Other NUmz&3?J-3-p?—S E)MRA oN DATe "O <br /> G Z0GXATNMJI.INFpRMATtON: (:oardiRstes X Y_ Township W.rtgs SaeWS <br /> Itsa llJiL >orwec/Pnvate 0 Irtigsrioo/Agncuhuraf O Indus") D Nater Quality m,,rin firing 0 Soil Sampling/Chaneteriisto n <br /> O Public Water Sysien, <br /> IrdifF�mcfrom 0.rsr �m smr -�---T,o;dci77�•,,�ipe.-1T,�,-------� <br /> i TYPL_OF WORtt fi*ew Well O Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0Monitoring Well(s), of ells 0Soil Bonng(a)_ sO/s'r OGeotechnrcsl soft-0 <br /> D Out-0f--Scree Well 0 Out-0f-Service Well Rrnewal 0 Cross-Co nocuon Repair <br /> Ne.v Pump ❑Pump Replanemenk. 0 Pump Repair <br /> AUL CONstRUCTION <br /> DrIBIaK MethodVAII dud Rotary 0 Air Rotary 0 Auger O Cable Toot 0 Push Pram D Other <br /> i Proposed Well Dept"? 90 ft Excavatio. I t •in dirmict. 0 Open Bottom 4.vel Pack/Gravel Size ,in diameter <br /> 0 Corduc Cuing ___in dram,-ter / Conductor Casin Depth fl <br /> Well CadRS Diamety/ in Thiclmeas/Gaugc/ASTNt Schad S. O Steel�p4anc 0 Stainless Stnel 0 Other (n <br /> (:roar Stat Depth L1 ft 0 Neat Cement 04 Ib bog/5-10 got warrr) )r45&nd Cement /(�i sort mix/7 gal water <br /> r <br /> O Bentonite(201/.solids) 0 Manufacturer Spec%solids Name _ 0 Sped on File 0 Specs Submitted <br /> GuNwt Flawewest Method 'Pumped O Fri Fall 0 Oder_ 0 Rowdom/Accelerator(name) hl <br /> UMnAL ISstalled By Dnller 0 Pump Contractor 0 (),her <br /> 0 Caoertu Pedestal Dlmemlono.Width (,[_ _q Lrngth _ ft Thick in ❑Chrlsry Bes CI Btsva Mese r� <br /> ubtnetaibk 0 Turbine ❑Othn —�—HP -Pump SN_ H Surding Water Level ft I J <br /> 1 HEREBY CERTIPY 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 LICYNSE IS l <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL ?1 <br /> WORKERS COMPENSATION LAWS <br /> a <br /> INIMUM 24 HOUR ADVANCE NOTICE RE <br /> QUIRED FOR INSPECTIONS <br /> BIOMED _ _ ('nisl��/frc <br /> DATELT 1w�3 1, <br /> r <br /> Ef <br /> 77-7 <br /> - r <br /> OP <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted By Dau 3O U! _ Area Empioyee 100 53 Lr" %Gr <br /> Orout Inspection BDau. - i</c_ 13 SPECIAL Well Permit / <br /> Pump Inspact: L.r Dau i-Oidry/rTJ - O WAIN,ER Received <br /> Constructed Weil Depth n <br /> COMMENTS• Q L- <br /> FCO�dg <br /> SC Raeslved heck>f/ Amount Darr Invoke K Well IQv <br /> Ido B s Resifted Servite uest K <br /> -7v oto so Pec z-7a { <br /> em Gw'" <br /> Vl7rL07 <br /> wFI L PUI.B PEkMR <br />