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i <br /> WELUPUMP PERMIT <br /> SAA JOAQUN COUNT?ENVIRONMENTAL.HEALTH DEPARTMENT GOO EAST MAIN STREET•STGCX7014 CA 95202 •(209)4G93420 <br /> NON-REFUNDABLE PERMIT CALL(2119)9 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> M <br /> J�Lr.Lf1 TNkDA R.� <br /> JON ADDRESS '_1 Rae • CIr1rZ1" <br /> c ��y� ♦ „ L�Eu G7_ <br /> ICNOSS STREET V //V��D, I e APN �PARCEI SIZE 1'`s <br /> 4 LANG USE APPLICATION p <br /> (OWNER NAME ♦ PHOMC VL <br /> IOWNERADDRESS UDIiL__ CRY/STATEr1X` <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS D��1 �Cl'_/G... CrrYtSTATErZV 14r _ -j <br /> SUBCONTRACTORHPHONE <br /> SUBCONTRACTOR ADDRESS-__ _ - _ CRYIS7ATElZp-____ <br /> LICENSE C-57__G-61-13-0t-__ Other _ _ NUMBER EXPMUTION DATE <br /> GEOGRAPHICAL INFORMATION; Coordinates X Y Township_ Range__ Section_ <br /> INTENDED USE -"DomeadcJPrivale IrrigatioNAgrnrRural Industrial Water Quality Monitoring Sal Samphng Characlenzalm <br /> Public Water System-_-- <br /> `, N6rtr•m Forn Mnmr -.--------Wikr-5yAkm-Meme ------- ----- --- w Fri.-Rurr�iv <br /> TYPE OF Wows New Well Replacement Wel !i Weil Alteration/Modification Other erokek-Quo reg&fil?o-"--- <br /> Monitoring Woa(s)"___.. _ 0 of welt. I Sol Borings)_ • ' Geolochnical--- r 0 <br /> OuiAlServlce Wel .1 Out-01-Service Well Renewal CrossConnection Repair <br /> Now Pump PurV Repiaoemeni Pump Repair i Raise WRIT Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger II Cade Toni l7 Poh POW 0 Other <br /> Proposed Welt f7epUt___- N Excavation in dlitMlM Q Open llelbm Gravel Wsck/Gravel Sizein diameter <br /> Conductor Casing __m diameter / Canduclor Cssft Aqui fl <br /> WeltCesing Diameter_in Thickness/Gauge/ASTM Sched 0 fts1 in Plastic Stain ess Steel Other <br /> Grout Seal Depth "It Neat Cement(94 to bay5.109W dialed Sand Cement...... __sack mixf7 gal water <br /> bentonite(20%solids) i i Other <br /> Grout Placement Method Pumped ,FM Fall Other r',Retardant i Accelerator(name) <br /> PEDESTAL Insulted By Driller 0 Pump Contractor Other <br /> Concrete Podestal Dimensions-Width It Length D TWA in Christy Box Stove Pipe <br /> PMP Submersible Turbine Olhet _ HP Pump Sel It Standing Water Level it <br /> I WILL HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK LL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEPATION LAWS. <br /> I UM 24 R ADVANCE NOTICEREQUIREDFOR INSPE TIONS <br /> SIGNED _,_--- T. �E/�N�E DATE � / <br /> -: - - - - - _�+ - - - - - - - - --- - D <br /> -� - i3f g <br /> - ALTH <br /> 110,14- - - --- -_ - = ES <br /> ; + <br /> DEPARTME TC�yU EE ONLY r <br /> Applicalion Accepted By -____--- _ Date C�L_I U� Area_ --- Employ"I[$' <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By` Date - _ _- WAIVER Received <br /> Soil Boring Inspection By _--_ Date -__-_--_-_---_ Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Recaivild Amount Date PenntU —-InvoiaR ssa01101/ <br /> Codes Info By Remitted Service Request X <br /> ; <br /> DIV 430 WEII NVMP PERMri <br /> 61a•TC' <br />