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S+NRRca,NrE►,,,,RD ,,Tw, ,«,p� ELL/PUMP PERMIT <br /> NON-REFUNDABLE OUNTYE6WEAsyMAIN STRUT-STOCKTONCAM202 (209)468-34" <br /> r PERMIT CALL 2f 09)953-7697 FOR INSPECTIONS —EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS C / 3 if <br /> /J 4 cm/ZIP t' I c �S 3 0 A <br /> CROSS STREET C.:n�1Q 2p ra c` _APN� `— a <br /> CEL O^ PARSRELAND USE APPLICATION <br /> OWNER NATE ` <br /> 0 <br /> s <br /> _ PHONE <br /> OWNER ADDRESS 3) —� p i <br /> I.� �• � �~'•�•� ✓� CrTY/$TATEILP--_J t�Q <br /> CONTRACTOR 1t/eo 4 C" fi S's'1 , J�.� L .�d/9 BF4f/�yE <br /> =�— <br /> C. PNOW 2 e P <br /> CONTaACTOR ADDRESS _,00. BO Y. <br /> — Cml$TATF/jIP_L� <br /> SUBCONTRACTOR —� ---�—��—' <br /> — PHONE <br /> SUBCONTRACTOR ADOMSs <br /> 1� CITYI$TATEIIIP <br /> LlCENHE ,C-;,7 0 cat r.0--09 �1}-clu,er4�Z-/ e_�o nu►tBEx 73 �S3 <br /> EIPIRAnoONDAR .3 <br /> GCOORAPINCAL INFORMATION, Coordlnmles X Y I <br /> Township_ Range Section f <br /> �&M�QLLV;LDZ.s�,JPrtveteaIrtlgatlon/Agriathnal CI Idustriel _Water Quality MonitoringWater System ll Uhler. <br /> rr y. n time a ur are m <br /> LYPE OF WORR C New Well r]Replacement We* D Well Nle'raboNModdicetlon 0 Other <br /> 7 MonrlorkvWet(s) Oorweft C SodBonng(s) Oct h0mv, saeonno•. <br /> I OUI-Of-Service M41 .'I Goolechr"cal <br /> L,Out-Of-Service Wel Renewal C CMSS-Correction Repair <br /> CI NOW PUMEAmReDktMnenj 7 pumpRepair <br /> Orgl4Co 0 Raise Well Cast Iw r <br /> Method I I Mud Rotary 'Air Rotary L Auger 0 Cable Tool I Push Point -. Other \` <br /> Proposed Well Depth ft ExCavOtion In diameter ��D <br /> Conductor Casing pen Bottom C Gravel PadclGravet Sac In diameter <br /> g in diametor I Con Casing Depth N <br /> Well CaSealing Depth f_m ThidmesslGaugelASTM Schod <br /> 0 Steel 0 Plastic C Stainless Steet - Other <br /> Gran Seel Depth h D Neat Cement(9/tD 6ag/3-10 gal waled _ Sand Cement <br /> n BentoNte(20%solids) -_Other SaCk mixR gal water <br /> Grant Placement Method I Pumped L free FBS -IDow <br /> --_--.�_ 0 Retardant I Accelerator(name) <br /> PEQFSTAL Mata Ned By :. Onller L Pump Contractor Other <br /> 'j COncfstn Pedestal Dimensions.Width_ rt Longlh R Thick <br /> --in 0 Christy Box = Stove Pepe <br /> StAlmervble Turb,; ,1�_ F.tp <br /> P SetR Slandiag Waley Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE �� <br /> WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOACMN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN IN COMPLIANCE WITH ALL. <br /> WORKERS COMPEINSATION LAWS. <br /> SIGNEDMINIMUM HOUR ADVANCE NOTICE ff QUIRED FOR INSPECTIONS <br /> ITL , , <br /> TE_1�`'t^-t � � ` <br /> I�c t �•'.n DATE / /O O <br /> T TT <br /> ENT <br /> LVED <br /> g 2008 <br /> N UIN COUNTY <br /> NMENTAI. <br /> EPARTMENT <br /> Application Accepted Date Area Employee I08;]�t1��e�� / <br /> Grout Inspecoon By SPECIAL Well Permit r (( <br /> Pump Inspection ay WAIVER Received <br /> Soil Boring I action Sy Constructed Wag Dept R <br /> COMMENTS <br /> PE SC Revived ChOckNl Amorrlt -- — <br /> PormtV <br /> Codes Into 8. Cash Ramftted Date SmicO Request A Involes R WON IDN <br /> END aI-OS <br /> WELL 11"rP fYRMIT <br />