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WELL/PUMP PERMIT <br /> SAN JoAtiltis Couvry EsvikoNall HEALTH DIEPARTMEN Ir 344 E WCHER AVE T'FL-STWATOX CA 9$202 4611-3420 <br /> NON—ftM,4iDA9LE PERMIT CALL(20)953-7697 FOR I ssncrjolis EXPIRES I YEAR FROM DATE ISSUED <br /> JOS A011AESS -Z3 A/ <br /> td- <br /> r <br /> CROSSS'1lzlle-4- K I 124- �:p APIAPA9CEL SIZE ILI—9--ND USE APPt.41CATION <br /> 0",ER NAWE d s IPHo.NE I <br /> 60� <br /> OWNER A6614r," <br /> IV C'MISTATI ZO/9wkei;*- <br /> CONTRACTOR M <br /> .... <br /> CowraAcroiu AariRcssiA .4 A:IC11-ir 24., CITV^rAT1-1Q1P <br /> SA'slCON1,0AC-rowl <br /> SVOCONTRACT09 AtibillISS <br /> �LIC8-441E 4C-57 CC-Cj MD-09 0 Other EXMRATt0%i DATE <br /> GIOGRAPHILALINFORMAI-JON; <br /> v _ , o <br /> 14TEPDw — <br /> Ust Cl)--,le/Prtvale 0 fmplioriJAgncultural CI frAoxinal 0 Wow Quality Moil arinall; a Sol?Samptirl <br /> 21 <br /> M l"Jal lit water sysi,-,) <br /> TYPE OF WORK cw Well 0 Rtpwcff=t Well 0 W)1 13 Test i"t <br /> 11 t Cr 4Chlie:r <br /> E3 <br /> monitoring wcll($)­ Cl Gootechnical <br /> 0 Well Dmric-= 0 Oul-Of-Sen-3ce Well 0 Out-4)r-Service Well Renews, <br /> C3 New Pump 0 Punp.Repl.ttemcnt in Puny Ittv-11 C Cro%:Connection R"ir <br /> WELL <br /> Drilling ud Rotary 0 Air Roury C3 � r 0 Cable Tool 0 Push Pvint 0 Other <br /> =d,�C4 ...... <br /> 7 in diameler. 0 Olilm Bovon) 0 Gravel?ji:k I Gravel Sin let diameter <br /> CS Proposed Wali neptfi.!93iP-f,-,.fl Filea"tir"l-, <br /> in diat.wie i Conductor Casing r.�Vptj% <br /> WC41 Casing C$ia= I <br /> Tblc.1tnMk3sug;A/AS7MSchell IAPtr�) D.Suxq ;tic 0 SuPtilkS5 Steel 0 Other___ <br /> .IAP.........— X-1. ..... A <br /> Grout Stat Depth-AX-9 —A 0 Sand Cement-...................-sack ma 17 Sal watelt r- <br /> 01�brnuimur(20%solids) 0 Manufacturer Spec%solids—% 0SP%sonfill: OSplWaSubmirted <br /> Groat PluetnWA(Method OPumpcd 0Free Fall a Other 0 RttardArAlAcrteltralot(Antric) <br /> jPEDENTAL Initallird By 0 Drifter ump Contractor a Other <br /> 0 Costriete Pedestal Dvalejilawts. wid*,.., — A L,imp­ R Thick in aChristy Rox E7 stave <br /> Ptimp 0 Submersible cTurbme 00thet-- lip­ Pump Set—11 Standing Water LaV41 ft <br /> WELL UESTR"'TION 0 Oper,Bottom 0 ciravel Pack M u6c4m:d C Odw. <br /> Well Diantew,_in Total Depth fl. Deptr.,to Water fi 0 Cuing to be Perforated from—11 to fl <br /> Staling Material 0 Neal Cement(94 lb bog/JJ0 giq w,,,) E3 Sand Ct;mftt Jack rain 17 gal W*w 0[I'muinile Pellets <br /> a Rentriciae(20% bcA <br /> solids) 0 Manuuter Spire%solids Namet aspecAeartic oSpecs Submitted <br /> Ptlartment mitthoiri C3 Pumped 0 Free Fall 0 OfficeI <br /> 0 Complete with MUS11MOM C410 a helow grali, 0 Complete to Existing Surtacc Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TjjE WORK WILL RE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND RECUIATIONS, I ALSO CERTIFY THAT MY RE(AARED LICENSE IS <br /> CURRE14T AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM INCOMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> tJ MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR 14NSPECTIONS <br /> TrEa \ .i DATE, <br /> 7- <br /> Fitt a.kit <br /> 117 17� <br /> I II 11AbU <br /> r i,Ap noN <br /> w-A THD- <br /> .1 L& <br /> EPARTMrNT USE NLY/ <br /> Application A :epted Area l L_ PIT.,Jv.—IDa <br /> E3 SpEnAL Well Permit <br /> DA <br /> Grout Inri as may, <br /> pitimp Inspection By Nit 13 WAIVER RtttiVeif <br /> Destruction Inspection,By ....... Dam- Constructed W011 Depth It <br /> COMMENTS <br /> —2a <br /> 1 PC SC Received Cls-ii A nowart T Pen"tV <br /> Coil 1014 at Remitted Dart StrVite Reg-at 0 lavoke A Well 110110 <br /> f <br /> 3S 6 S- <br /> ltSTER WATIA WELL PERMIT <br />