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A I WELLJPUNP`ygRMIT 803230-71 <br /> SANJOAOUINCOUNTY ENvRiommENTALHEALTNbEPARTMEHr 1968E&PHAZELTONAVENUE-STOCKTONCA952011-(209)46e•12Q <br /> NON-REFUNDABLE PERMIT GALL 209 9531697 FOB.INSPECYIONS"" FXPIR9S T Ygm FROM-DATE ISSUED <br /> '0 <br /> cADRTwEBcr � 9iLis S. P''b" (?,d <br /> ErtY1d (?l^^ � --IF , ] <br /> bb <br /> A. 4A,.1 AVN 1,41'l. L,Y>PARCELSQE/ 1jLANDUSE APPLICATION# <br /> /p <br /> - PHONE 1531- <br /> CONTRACTOR �'�fZ�Sy�`���(I 3 ilk k i(9 <br /> CONTRACTOR ADDRESS I'I I I7'/��✓•� I."d CITY/STATE2N <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS -.CITY/SYATEZP -7 <br /> LICENSE 9.57 n C-BT n D-08 ❑Other NU71BErt ExPRATK*DATEZl: �/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y - Tdwnshlp_ Range_ Sactlon_ <br /> IHTENDEDUft QDOmellio!Pliv.l. a WigatioNAgricultural O Industrial, D Water-Ovallty MoNloring C.SoilSampling/Charactedzatlon <br /> q It dh.l,.nl(BierO seam %19,Sygl,m Name Canl.d N—or u r <br /> TYPE OF WORK ONew Wall eplacemenPWell O Well AlteratlorJMDdllication O'ODler <br /> O Monitoring Wells) #of Wells ❑Soil Boripg(s) *"'Wkw 0 GeolechNCal I dWfts <br /> I COut-Ol-Service Well O OUt•Of•Sereice Well Renewal• O Cross-Connection Repair <br /> i n New Pump C Pump Replacement ❑Pump Repair ❑Raise WallCasing <br /> WELL CONSTRUCTION <br /> Drilling Method) Mud Rotary ❑Air Rotary ❑AUger U Cable Tool U Push Point ❑ Other <br /> Proposed Wall DSpiha7yj? _R Excavation 1—In dameler D Open Bottom ravel Pack/Gravel Size in diameter' <br /> O,Conductor Casing In diameter I Conductor,Casing Depth h <br /> Well Casing Diameter&in ThIckness/Gauge/ASTM Schad dfJ U Steel I!plastic D Stainless Steel 0 Other <br /> Grout Seal Depth/QD fl n Neat Cement(94 Ib bag15-ID.gal water) ❑Sand Cement sack mW7 gal water <br /> �entonite(20ys solids) U Other -. <br /> Grout Placement Method solids)D Fre.Fall 0 Other U Retardant/Ilccelerator(name) <br /> PEDESTAL Iro¢Ned By D Driller y_Pump Coniractor O Omer <br /> n Concroto Pedestal CDimenetons:Width_g. Length h,-lek In 0 Chris BoK 0 6 rwp1I <br /> I _ <br /> ., C SubmerslbleU Turbine 11 Omer HP Pump§qt D StandingWater Leval E <br /> (HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND' A7;T,HE WAR WtEI BE"DQQll{{�E�'1!F ACCORDANCE'WI1R1 SAN <br /> JOQ¢UIN COUNTY ORDINANCES,ISTATE LAWS,ANO RULES Abl!p=A TIONS.«' SFI CEi?Rf- 'FNItIF'MV,HECBtREb LfCEN52"I <br /> CUhRERT AND ACTIVE WITH THE CALIFORNIA CUNT) <br /> STATE LICENSE BOAPID AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. I <br /> MINIM UR 24 HOUR, TLE/''ADVAI CE NOTICE REQUIRED FOR INSPJ,EEOTIONS PLEASE CALL(•209)953-7697 <br /> SIGNED V l I RAC.&,Z 'TIl�(!1'` DATE <br /> 1 <br /> W U <br /> C W <br /> t, --F - D" TMENTrUL�.Y <br /> Application Accepted By Date E�P Area V la 1 Employee IDIS =i f IVL <br /> Grout InspecfionBy Rate ❑ $PFCIAL We Permit. <br /> Pump NupectbnBy Date•�_� ❑ WrAIYER-Rece(Ved <br /> Soil Boring Inspection By Data ConsVt{dtod Well Depth N <br /> COMMENT$ LZ L{•l /r %i nJ7h <br /> PE SC RtrFalved CheokN Amount Date - Permit/ Invoice 0 Well[DO <br /> Codes kdo 7 11Cash Remitted Service R,✓/uest BJ_ <br /> i <br />