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WELL/PUNIP PERMIT <br /> SA-j Jo,%Ourj Cou;-jr-t E:r,,iR0rJLIE:J7AL HEALM DaPARTf.Ir_,-jT 13,i3EAsr H,%--ELr,);j AJS;,LE S CA 35205.6232 (203)463-3410 <br /> N Cill-P-Elz U PiOABLE PERMIT ci�PllssuEo <br /> -- <br /> LO <br /> ic,"s S E-z A -93 OiD <br /> pri P P-EL SI:s24-f,1jPf(_La;4c Us' -ICA 710fj <br /> _J3 <br /> r"Li LA Ir...-)l I. D IU!r;J 0— <br /> S <br /> E t L <br /> iOWNER A00PESCa-i,Lj CITYISrATE,GIP A <br /> CONTRA,_'TOR �k) PHONE <br /> CONTRACTOR ADDRE35 CITY/STATEI:ZIP &1li <br /> SUSCONTRACTOWCONSULTANT V060 ILI! PHONE -q�b) <br /> SU13CONTRACTORiCONSULTANT •ADDRESS Ajtl CIT1/STATE)ZI1 a^_ <br /> LICENSE V✓S. 031 D-09 Other- NufABEP ExPIRATIONDATE <br /> BILLING PARTY: OWNER CONTRACTOR <br /> DOMESTIC WELL SAMPLING:_General Mineral,'Coliform Bacteria(4391)=Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE =Domestic!Pnvate I lingafion/Agricultur3l -_ Industrial Water Quality Monitoring - oil Sampling/Characterization <br /> Public%A/ater Svstem <br /> If Jifferent from Ovi-, VIi.ter SyM.m.•I- Cailtact Name)r?hone Number <br /> TYPE OF WORK =New Well Replacement Lyell .v`/ell Afteration:Hodificalion =Other <br /> I Soil Boring,S) ''f owngs ­­gs <br /> Monitoring Vlielksi_ if ells . Geo(achnical <br /> .7 Out-Of-Service'Alell .- out-Cf-Saplice Well Renewal = Cross-Connection Repair <br /> -_ New Pump Pump Replacement -Pumo Pepair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -(Mud Rolar­/ =Air R.,Ia,y -4u,er Cable Tool :Push Point - Other <br /> Proposed Well Depth j If Exc3valion_in diameter - Open Bollair -Gravel Pack,,'rjraval Size_in diameter <br /> 'Conductor Casing_in diameter Conductor Casing Depth_it <br /> Well Casing Diameter_in TIiicknPs.s,GaugeiASTM ached - Steel = Plastic i: Stainless Steal - Other <br /> GroutSeal Depth i's rt -fleat Cement 19-('b Sag,5-10;31 wafir) =Sand Cement_ s3ci(mf..i-, gal water <br /> -Benlonite,20'.solids) - Other <br /> lGrout Placement Method .Pumped _ Free Fall IKOth-al <br /> PEDESTAL Installed By t Driller Pump Contractor = Other <br /> 7 Concrete Pedestal--Dimensions:Width_ft Length_ft Thick in -l-Christy Box -_Stove Pipe <br /> PUMP Submersible?Turbine Other HP Pump Setft Standing Water Level fl <br /> IHEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I <br /> OAQUIN COUNTY ORDINANCES, STATE LAWS, 00 RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI YYM,48 HOUR DVAN,CE NOTICE REQUIRED FOR INSP��TIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE FV7rA I DATE <br /> D <br /> NT <br /> 1 1+51 1 1 1 1 1 1 1h __j 1_j V <br /> 1 I it <br /> 6 2021 <br /> EP <br /> IN COUNTY <br /> EGIRAMEN7AL <br /> _TIq L.�F—:ARTMENT <br /> DEPARTMENTEONLY <br /> � <br /> Area Employee I D# < <br /> Application Accepted By Z__z Date <br /> GFOUI Inspection By Date SPECI L Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date CoI I ft <br /> 4 <br /> COMMENTSA/P 011G- 17n '70 "uctXWeIZeP" <br /> r" IF <br /> ed Check#1 Amount <br /> PE SC Received Dale Permit/ Invoice# Well ID# <br /> Codes Info A$? sRemitted Service Reque_V.4 <br /> 11 7tl- C) <br />