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• • FILE COPY <br /> /Va s <br /> G �No a4�vELL/PUMP PERMIT <br /> -' gANJOAQUIN CODNEY ENVIN(INnIIINTALIIFALTIIDEPARTaIEN! SR4EWEBERAVEPIRESl'OCNTON CA 95202-(309)468J4I0 <br /> NON-REFUNDABLE PERMIT CAIT(209)953-7697 FOR IN%PDCTIONN EXPIRESI YEAR FROM DATE ISSUED a <br /> FCROSSSTRE�T <br /> e ?t . / 'To,CiTv2v pppppp //////)))))) TT OOrnip��)K GP1��V ^'!/ APND89-1)(j59 IPARCELSIEE LANDDSEAPPLtCATIO- P <br /> PIIONEy Z <br /> C /STATE&LIP �ECE • ,l •' F SRDNE zaEr-3r,7-a�6r ,�162 T 'ADDRESS <br /> PHONE <br /> SBBCOMRACTO /VG.( <br /> CITYISTATE/ZIP <br /> SUBCONTRACIORADDRESS /�Q <br /> NUMBER (/�J E%PIRATION DATE OO <br /> LICENSE C-57 El C-61 0D09 ❑Other Range_ Scadon_ <br /> Y Township <br /> CEOCRAPIIICAL INFORMATION: Coordinates % <br /> INTENDED USE ODommtic/Privme 0lmgalion/Agdmlluml ❑Industrial ater Quality <br /> Monitoring ❑Soil SamplinglChanctedmion <br /> O Public Wafer System Ir s31L .me un smear om um r <br /> Ifdi@mM m — ae <br /> TYPE OEWORK [I New Well ❑Rmlaelnrnl Well O Well Abaration/ModiRcation ser 0Tet HDle DOther cal__aoreounTs <br /> XManitoring WER(s)�_Kofwells El Soil BerinBb) <br /> E3 Ow-OF-Service Well ❑OBt-0f-Service Well Renewal <br /> :3 well Earn tion ❑Cross-Conn/oreio�'n�'Rit <br /> ❑New Pum ❑Pum R lacemrnt LL//❑Pum R it III�'I13 w�-� <br /> WELL GON.STRUCTION ❑Air Rata 1Mu8er cable Tool ❑Push Point Bohm <br /> Grilling Method ❑Mud Retary Rotary Proposed Well Depth rho R Excavation indiemeter El Bolwm ❑Gavel Pe/<//Gnvd Size rEr <br /> in dianlemr I Conductor Casing DeptM1 R Xj pll/�D D/9s y� <br /> O Conductor Casing V <br /> O Steel KPInatic 0 Stainless Steel $ANnr <br /> Weil Casing Diameter in Thicknes�s/„Gauge/ASTM ScM1ed, "'l sack miT/7 gal water <br /> Grout Seal DeptM1 M R kNEat Cement(94 lA hag/5-IOgalware) ❑Sand Cement OSpxs on File ❑Spas Submitted <br /> 0)3cntnnite(20Y solids) 0Manuhctum Spec%solids_% Name <br /> 0 Reurdan:l Acceletator(name) <br /> Grout Placement Method tamped 0F.Fail ❑Other ❑O{hm <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor <br /> in C30611113.. ❑Stove Pipe <br /> c..Erele Pe4mn.l Dimensions: Width_fl Length Pa. Sct_R Standing Water Level R <br /> ❑Submersible E3 Turbine 001hcr HP__ P <br /> PUMP Other <br /> WELLDENTRUCOON 00prn Bottom ❑Gravel Pack ❑Unasad <br /> Well Diameter_in Total Depth R Depth toWats rt OGsing lobe Pcrfo[IRorated ma__ft'lo_R <br /> Scaling Material ❑Nal Cemm�t(941h/wg/5-10gu/Worn) O Sand CEmcm__•urk our l7 gal wmer ❑Ba aFil Pallets <br /> ❑ManutkcluuWS .%soliEs_% Name ❑Specs on File •O Spas Submiacd <br /> O�Bcntonim(20%solids) Pc <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap Bbelow grede ❑Comple¢roEzixting Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> ES AND REGULATIONS. I CURRENT AO DNAC E ORDINANCES, <br /> ITN HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD <br /> TCERTHAT 1 AM IN COMPLIANCEFY THAT MY REQUIRED LWITNSALL <br /> RVORK5RS COMPENSATION LAWS• <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS OGT a L <br /> SIGN TITLE FrU) �1IA DATE <br /> L5 <br /> f DEPARTMENT USEONLY <br /> Date Arm Employs ID# <br /> Application Accepted By Date [I SPECIAL Well Permit <br /> i Grout Inspection By WAIVER Received <br /> Pump inspection By Z a <br /> eructed Well Depth <br /> j Destruction Inspection By .k j <br /> COMMENTS <br /> i <br /> PE SC Received Cheekq/ Amount ' <br /> Dale PermiU Involceg Well ID# <br /> Codes Info B <br /> Cash Reunified Servls Re uotp <br /> (b <br /> MAStER WATER WELL PEEN <br />