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SAN JOAQUw NV <br /> COUNTY EIRONMENTALHWELL/PUMP PERMIT <br /> �DEPARTMENr 304 E WEBER AVE 3rD RTON CA 95202 - (209)46"420 <br /> NON-REFUNDABLE P�E/RMIITT c /y� (ALL.(209 9j3_-69^FORINSPE(I.... EAP ECI YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ar i.�X y <br /> ,I n� ( CITYR@ /'A2/ /d9 9x37 <br /> CROSS STREET L(Aj ver h✓1 APN ZJ3^ PARCEL SIZE <br /> __ LVNTi�Iy� ji1�11A(/I/ZT�f( / _LANG USEEAPPLICgT0NX <br /> DWNERNAME 4AV�7WIL77C ,--- PHON <br /> O"ERADDRE55 2JOq <br /> �2 Ct'PY/$TATErT.@ T/J�6rJL � ,• X <br /> CONTRACTOR �iy (NV PHONE/ <br /> CONTRACTORADDRESS LA/y0 f�'7/JsSLIK 31r•l t Y <br /> rr11 ,� I CRT/STATER@C-4,.Lr.�Td� <br /> sDRCONrRALTDR WnC GXPLnn�/1.0 �- Wr[a—< T I�'E HE T <br /> /�JJ �� PHorve <br /> $UECONTRACIOR ADDRESS �O ( (!Y yA/7-✓ /LO:di� IJ(7 CPrYBTATTVZ1P ¢/ p,, <br /> LICENSE 6-57 ❑C-61 ❑ .FA <br /> D-09 ❑Other NUNDER 93324v EXPIRATION DATE { 2-W6 <br /> GEOGRAPHICAL WFORMATIO Coordinat. X Y Township Range�f� Smtion� <br /> INTENDED Ilse ❑Domesti rivwa ❑Imigntim/Agricullural ❑IndusMe Water Quality Monitoring ❑Soil Sampling/Chemeterizntion <br /> ❑Public Werer System <br /> IIdlOewnt Rrm Owns .Rr ysem ame Down .mew one um <br /> TYPEOF WORK ❑New Well ❑Replacement Well ❑Well AlteretioNhledifsabon ❑Other <br /> Monitoring Well(a) !—# f.11. E3 Sad Borings) #41,runp ❑Geotechnical Enfbminge <br /> ❑Out-Of-Service Well ❑Out-OfSarvice Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑PumE Re lacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary— M Air Rotary >Z�Auger ❑Cable Tool It Push Point ❑Other <br /> Proposed Wall Depth I 2 ft Excavation & <br /> n <br /> in diameter ❑ppm Bottom yy Gravel Pack/Gavel Si.'*P 2. is ' er <br /> ❑Conductor Coring in diameter / Cordudor Casing Depth fl .,/ <br /> Well Casing Diameter �l_in Thickness/G,,yASTM Sched q0 ❑Steel ❑Plait ❑SMialessswal ;1Olha ✓C <br /> Grout Sul Depth /Fye ft Neal Cement(94 fd 6ag 1540 of svmes) ❑Sand Cement sack mer/T gal water <br /> ❑Benbnite(20'/o solids) ❑Manufacturer Spa%solids % Neme ❑S son File ❑S <br /> Grout Placement Method Pec pen SubmiRN <br /> Pumped ❑Free Fall ❑Other ❑Retardant/Acoeltma or(..a) <br /> ...avAl, Installed By JKDriller ❑Pump Conuact9y5a 13 Other <br /> 0Cour-1-P estal Dimensions:Width .J R Length RThick in ❑Christy Boa Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Hh HP Pumps t flStanding Water Leel fl <br /> 1 HEREBY CERTIFY THAT 1 DAVE PREPARED THIS APPLICATION AND THAT THE WORK W <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIODONE IN ACCORDANCE WITH SAN <br /> CN$. I ALSO ILL ILL BE BE THAT MY REQUIRED LICENSE IS <br /> WORKERS COMPENSATION LAWS. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> CU <br /> 1 IINIMUNl 24 1101 R AD),ANC.'E N'O'TICE REQUIRED FOR I,VSPEC,IONS 2 <br /> ^' SIGNED r DAT63 236 <br /> TOLE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dale 6 4 Area 9—f 7 Employee mg <br /> Groutlnspection By Date ❑ SPECIALWefl Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Conslrurledlpept fl <br /> COMMENTS llll <br /> PE SC R.',M Ch / Amauoe Permit/ <br /> Cod. Info B C Remitted Dal° SarviieRegiaasth Invoice Wall Ipµ <br /> J90 z n 6 2( <br /> elsomuxma <br /> 1/!I/10J5 WELL PUA@PERAR'f <br />