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WELLIPUMP PERMIT <br /> SAN JoAcuw Coomw Emetomma rAL HEALTH OrPARTIENT 1868 EAST HAzELToN AvEmw-STc curoN CA 95205-(209)468-3120 <br /> NON-REFuNDABLE PEERMITLL1' 44CALL 2{09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AooREss .�3 C.' 1?V,l'/i!•1 / Cayaw 17 5 <br /> CROSSSTREET L`/G/�,&A �►ra APN -�U f Q� Doi PARCELPARCELlo <br /> SUM " LAND UsE APrurATN S og <br /> Ow ri;tNAAE --,.7Lt✓►WNER PNONE zocl-Lt ZI<-9L 1 i <br /> OADDRESS PU �� 3 U . CRYISTATERR .j-r C O t) �t mP I�Of / <br /> CowrRAOToR tia.nA SH 9-L-!- Xd P.., Z09-St1 9-34S-1, <br /> CONTRACTOR ADDRESS C.'���J (�{(C-1L�� CrrY1SYATE 00, A rt ho q r:r& <br /> SUBCONTRACTOR PHONE <br /> SuacONTRACTOR ADDREss CrTYISTATErLw <br /> LIcENsir C-57 t,,661 :3 D-09 -Other Nta®Ert 115j 2q S EtPet .DATE <br /> DorEsnc WELLS :u General Mineml/Coliforrn Bacteria(4391)_Dibromochloropropane(4392)-Arsenic(4393) <br /> InranocO UiE De—sbi rnvate 'J IRlgatbNAgrctRnral _Industrial '_'Water Duality Monite" :Sod SamplirwcharaClefY"rbon <br /> Public Water System <br /> e debeal hwn Owner Water Sys N— Caraad Name or M—wnear <br /> TYPE OF WORK New Wen ❑Replacement Well 0 Well AllerabonlModibcabon EI Other •���( �/ <br /> C Monilonn9 We11(s) II of wigs Sal Boring(s) s d oar:nprl <br /> s Geolerhical sol°o`"n <br /> C/►I Te <br /> .'Out-OfS&M Well Out-Of-Service Well Renewal 71 Cross-Connection Repair ` D <br /> Am Pump u Pump Replacement Repair L'Raise Well Casing Alit <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary Air Rotary E Auger -Cable Tod --Push Point _ Other 10 F 2010 <br /> Proposed Well Depth It Erkcaration in diameter Open Bottom (xavel PadUGravel Size ir�ft4U) <br /> Conductor Casing in diarnetel / Conductor casing Depth It LTH NMFNOUNT y <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Srhed Steel Plastic C Stainless Steel 2 Other <br /> Groat Seal Depth ft Neat Cement(941b bag/5-10 gal water) ❑Send Cement sack m&f7 gal water <br /> -Bentonite(20%solids) :Other <br /> Grout Placement Method =Pumped =Free Fag -Other _Retardant/Accelerator(name) _ <br /> PeDEsrAL Installed By Driller _Pump Contractor - Other C^L--;&I I- <br /> Concrete Pedestal ZDinensionsVA&h ft Length ft Thck in :::Christy Boz =Store Pipe <br /> timersible-Turbine �:Other HP_Z Pump Sen /LC R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I RAVE 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> if 1UA4 4SH ADVANCE NOT ICE REQUIRED F,OI1O!NS?EC i�; `iS-PLEASE CALL(209)953-7697 <br /> SrtaEn OlYe/L' l Trn.EI:.U..i:1-;- t�1 t,'-kl 5 DATE�--5 zt: <br /> I�( <br /> DEPARTMENT DISE ONLY <br /> Application Accepted By Date '/3 d$71U Area Employee IDs _.. <br /> Grout Inspection By Date O SPECIAL Well Permit <br /> Pump Inspection By I-/- Date 11.1 I /I-P ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC I Received check47 Amount Permit! <br /> Cortes into PAmilfed ete vests Invoice i Well we <br /> 143�'DJ 1 hu <br /> A <br /> 1 <br /> EHD430e rer®d4r14r18 VVELUP IW PERTeT <br />