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WELLIPUMP PERMIT <br />SAN Joaaul Cowry EmvwmNENTAL HEALTH DEPARTI®Nr 1868 EAST Hn2ELTON AVENUE - S7oexrorN CA 95205 Ni232 (209) 46&3420 <br />cvotoGc 4 VrAo conu IIATF ISSUED <br />NON-REFUNDABLE PERMI l �w�y� �•r••••• �iy• •• 5 �• — �Lcr <br />.108 ADDRESS -7 "�1 �i�'h� V _ _ CIT MP 9 r3 3 7 m <br />_ I D <br />r ^ __ �_LAIO USE APPLICAnON i A <br />CROSS STREET !� , H. `APN J UJ _PARCH.SRE r rt <br />OWNER NAME �� 1:?=y P,. log — 3 9 4 a <br />OWNER ADDRESS _ n��n (� "S <br />CITYISTATEfZIP <br />Comn ACioR `J PNONE .� bpi h <br />CONTRACTOR ADDRESS 1rnr11AT.1Z.Pt)n Y,{ <br />suacoNiRACTORICOMWLTANT _ PHONESUBCONTRAcToff/ComsuL-- <br />TANT ADDRESS CITYMATMF <br />LICENSE o C57 VG.1 L D-09 D Other _ Nureat�� /_��� EM11RAT10N DATE <br />Ba -LOG PARTY: OVII1lER 0 CONTRACTOR D SLMCONTRACTORtGONSULTANT <br />DOMESTIC WELLS _ U General h, Gneral/Colrfotin Bacteria (4391) u Dlbromodlbropropane (4392) u Arsenic (4393) <br />17RQer-f-E esticfP to n lmgabWAgn0AWral C Industrial 0 Water Quality Monitoring 0 Sal Sampling/Charadenzation <br />n Public Water System <br />Ir dilerer,l horn Owrw: 1Na4er System N— Corna'R Namma <br />Name or Phone NuO <br />TYPE OF WORK i I New Well i i Replacement Wei i Well AOerationu Modiliiration Other , of Gongs <br />I I Monitoring We0(s)-- N of wets i Sal Boring(s) a °r b nng. i Geotechnical <br />1 1 Out -Of -S, Well 1 1 Out-ofServioe Weil Renewal i i Cross -Connection Repair <br />i i New LYPump RepIpcement I I Pump Repair i I Raise Wei Casinct_ <br />WELLOOKSrRUCTIIDN <br />Drilling Method i I Mud Rotary I Air Rotary I Auger i i Cable Tod i i Push Point i i Other <br />Proposed Well Depthft Excavation in diameter D Open Bottom U Gravel PaddGravel Size— ir�divneter <br />c Conductor Casing in diameter I Conductor casing Depth ft EN V <br />We9 Casing Diameter _ in ThMamss/Gauge/ASTM Sched Steel =Plastic 0 Stainless Steel ---Other <br />Grout Seat Depth ft I I Neat Cement (94 lb bag15-10 gal ,rater) ri Said Cement ssck rra,df <br />i I Bentonite (20% solids) i Olt,er <br />Grout Placement Method 7 Pumped 0 Free Fall U Other Retarded / Accelerator (nar^e) <br />PEDESTAL Instated By _ Driler : P,anp Cor,lrador = Other - <br />Co Pedestal Dinenskxts-war, a Length tz Th& in Ch -sty ami Stove <br />PUMP Wnersibie- Th. = Ott. HP pumvS-4 R :y'IY�er —"ei t .� <br />r><rc r arr'•rhonAYrf tA[TN Sill <br />1 HEREBY CER71FY THAT I ItAV t "ot:rNm, r r.� >•,.,.+ TttA7 >t'( t rsallSF S j <br />JOAQUIIN COUNTY ORDINANCES. STATE L VM AND RULES AND R5GLlILATIDIKS- I ALSO CSZTFY 9 <br />CURRENT AND ACTTVE Wr rH THE CALFORMLA CONTRACTORS STATE -IC96E BOARD AND THAT r AN IN I".JIIIIIPL} - VAT" ALL <br />WORKERS COMPENSATION LAWS - <br />c - FL=AE_ C4: 249; 95i-= I9i <br />J�JIMUM r R ADVANCE NOTICE: REQUIRED FOR ikSPE s��:_.y�i.. ) Z <br />t/�•'. ,z.,--���•�.1 T[Tt E i /XI � IYE K'L L. 3� = l �� �.�1 � <br />, <br />LV <br />DEPARTMENT USE ONLY P/ <br />E--� <br />Apptiration Accepted By _ Lf !'- paeo (I �C �✓ Area S �i * r,•.c� I r I 7 <br />Grout Inspection By Date = SPECIAL Well Permit <br />Pump Inspection B Date \Z 12l = WAIVER Received <br />Sol Bon ng In\sppect o By Cale _ T Constructed Well Depth R <br />COMMENTS C \Z%�1 11� �,LI <br />