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` WELL/PUMP, PERMIT <br /> _'\ SAN JOAOU;N Cowry ENVIRONMENTAL HEALTH DEPARTMENT '868 EAST HAZELTON AVENUE-STOCK.-ON CA 9520$•(209146&3420 <br /> ,tl`/l/J►�[_J� NON-REFUNDAB E PERMIT CALL'L,2�'37 _CF INSPECTIONS I 1 YEAR M VlCm/ZP <br /> Auf <br /> CRG55 STREET APN _PARCEL SIZE LLANO USE�P�riy J DOvv <br /> •D�wNER NAME <br /> � <br /> a ' <br /> OWNER AODRE�v`/ <br /> CON-RACTOR An III PHONE,/' II <br /> CONTRAGOR ADORESS -6 L441 _— TY/ TAT P� <br /> 3LSCONTRACTORN .JA PHONE KI IPA <br /> 6L:8CONTRACTOR ADORES$"INVCICITYIIS�TAATE//ZP ,• , <br /> CE'i5E ^•-? C-p' D-05 0th W{.�lV V EXPIRATION DATE Cr.1 ^� <br /> .DOMESTIC WELL Srr UNG: General Mmeral/Collfonn Bactena ice; '; 3,oromochi0ropropane(4392) Arsenic(4393) C <br /> I ENDED USE OOmeS,IGP•Ivate Imgation/Agncuitir'al Industnal •Ai.ater QualityMonitonn <br /> 9 Sod Sampling/Characterization <br /> Public Wafer System <br /> if.tfennt fi,r Jvmer. Nater Syster,1a,e C01TW Name or Phore Numyrr <br /> TrPE OF WORK Ne'J-':Yell ReOlacemert Well Well A!%:ratlon:ytocifcat:on Other <br /> Monnonro:'Jellls, sof wells_ Soil 3^nrn; zof yonnga CaocDCnical <br /> Jus-Of.Sermce Well Out-O:•Sennce':'.ell Renewal Cross-CcnneCtion Repair >� <br /> New oumo P�.+t Rep:3cEr^_,nt Pump ReC.,: Raise Well:aSin <br /> YYEL-CONSTRUC_toN <br /> G^Hing Methoa MLO Rolan Air Rotary Auger Cao,c-c,,. "'Sh Point Other p\ <br /> Proposed Well Depth It Excavation s C:antter Open Bottom Gravel PaCK/G-aveI Size m diameter <br /> Conductor Casing in diameter Cor:!.Ctor CPS;rg Ceptn _ft <br /> Well Casing Diameter_.n Thickness/Gauge/ASTM Schec Steel Plastic Stainless Steel Other <br /> Grout Seal Dept ft Neat Cement(94/D oag,•5 J?al r,arCr) Sand Cement sack mixr7 gal water I <br /> 2entonite,20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant!Accelerator(name) <br /> PEGESTAL In talled By Driller Pump Comraaor Other _ y ^ <br /> Concrete Pedestal Dimensions:Width_ _an, ft Thick m .Christy Box $ ve pipe I <br /> °_reP Suomersible Turbine Other Imp Pump Set ftSand!ng Water Leve ft 7\� <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> -HEREBY <br /> COUNTY ORDINAN , Tq WS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS I <br /> CURRENT ACTIVE H THE CALIFO CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> 'NOR C PENSA NLA S. <br /> N UM HOU ADV C TI REQUfiRE�= s i_!�SPECTIONS-PLEASE CALL(20 *53.76S7 <br /> \C`+ <br /> SIGNED DA O •-�1 <br /> I I <br /> • I I I I <br /> i <br /> I <br /> I I <br /> i <br /> I I --- <br /> -- t I I I wC® <br /> _7 It COU <br /> R 11 <br /> I I N <br /> T <br /> I <br /> I <br /> - Iii I I <br /> =.oc�..mtlon Asaotec>y A�_ ,�j//-JC�f%y <br /> al_ Area Employee'Dzj�Ai,4 <br /> Dat: -di <br /> PECIAL Well Permit <br /> -;•repecbon B, Ota -a <br /> InSpecticn By <br /> WAIVER Received <br /> dui B:,nnD <br /> Consttvcted Well Depth <br /> h <br /> 'E SC Received i het Amount - — <br /> �05 S info B ate PSN <br /> '1 - 1 R mittec Service Re uesi# Invoice;* Well IDaY <br /> I -- <br /> WELL:P_,,4P zZRN;7 <br />