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WELL/PUMP PERMIT <br /> SAN'DA—" <br /> COUNTY EWRONMEHTAL HEALTH DEPARTMENT 600 EAST MAIN STREi i•STDeKTDN CA 95202-(209)4811-3429 <br /> rR.l�d2 / O_ -:O�SWREFUNDABLE PERMIT (209S5 - 7 EXPIRES 1 YEAR FROM DATE_ISSUED <br /> : <br /> JOB ADDRESS ` IfW MI. CR�% C4TY1ZIP To,46' 537 <br /> y <br /> ;b <br /> .r� -,1 �f�r q �f�7 o0 <br /> r CROSS STREET I�T N/5 APN �Q/` `W-�PARCELSIZE2'1 Z- LAND USE A�PUClATIONO ;m <br /> 5ZO L(S ra <br /> wig. rrNSm C�zZ- :e. <br /> OWNER NAME �/�]/�► 1A,-�{�.rr���r� P}1�+0/NIE� <br /> OWNERADORE55 ^�y�".r"-" �A•��'_N�Crh^�"�^I�►y'-,��C� �e �CIITYtSST�A-TElZIP�I�'YTC� ¢q[� r�QI)� <br /> CONTRACTOR LAII+"7t CAT{71 .7��?ts-c...*•-C- YyPII �^^�'���-t L"'L��- P[HO.E(2l�v3: -G• •4t <br /> CONTRACTOR ADDRESS-FO-1500 CITYISTATFJzw � `KO— ( C^` `(L 5 Z{ <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS .CIITY/STATIDZIP <br /> LPMSE %&17-67 C-61 _ D-00 Othor_, _`- NUMBER -3iL134 Exp(RATONDATE 3 2O�r <br /> GEOGRAPMcAL INFORMA-now Coordinates X Y Township_ Range Section <br /> INTENDED Use $Gu"",slA rp.V.tD ..InigaationOtIflcultural Industrial Water QuDllty MONtOring _Sou Sempling/CharaCienSIIhCn-+T� <br /> Public Water System .�.— <br /> If dalerenl lrom Owner: er Tsem eme Narrof or ph-.N..w <br /> TYPE OF WORK New Wel Replacement WelleR AJ teratloniModification Other <br /> Monitoring s) ,C wets 5 ilBoring(s) a`reorlrga 'I Geoterhnir�l tofb iigs <br /> Out-OI - rvice Wel It-Of-Service Wel Renewal •_Crow-Connection Repair t� . <br /> Now P um Replace ant _ Pum Re air "Rahe Welt Casing <br /> _Nr <br /> WELLCONSTRVG_114H l� <br /> Drilling Method Mud Rote -A r Auger Cahle Tool _Push Point J Other <br /> Proposed Wall Depth tt Excavation in diameter - Open Bottom ' Gravel PsWGravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth n �+ <br /> Well Casing Diameter_M•in Th'Ickness/GsugefASTM Schetl =Steel Plastic _ Stainless Steel DOW <br /> Groat Seal Depth ft _Neat Cement(94,1b hag/5-10 gat water) Sand Cement sack mlkq gal water r <br /> Bentonhe(20%solids) 'Other ^1 <br /> Grout Placemont Method - Pumped Free Fall -'Other -Retardant f Accelerator(name) <br /> P MIAL Installed By - Driller Pump Contractor -. Other ___._• _ �` <br /> .:Concrete Pedestal Dimensions:Width -if Length it Thicic in =Christy Box = Stove Pipe <br /> Putry $'Submersible""Turbine Other HP-3-_ Pump Set A Standing Water Level Q7_ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS s <br /> _CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> i NIMUM 24 HOUR ADVANCE NOTICE REQUIRED <br /> FOR INSPECTIONS <br /> SIGNED TITLE rte-'rel DATE �A <br /> E�q <br /> ` N <br /> DEPARTMENT E (ONLY <br /> Application Accepted By Date G [ a Area Employee IDa1 �S 9 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> fpump inspersion By ate WAIVER Received <br /> Sod Boring In on By Date ConstRlcted Wail Depth R <br /> COMMENTS <br /> PE SC Received Ch Amount Date Pormly Involve# We 14 loft <br /> Codes Inio 8 Cash Remitted Service R uest# <br /> �F3 Pt- two �� 2 3�� X50• W S'�°�3� icJ Qp 33 SL� <br /> Yr u/rump PERMn <br /> Ew.aos <br /> i_ <br />