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W . 1 WELUPUMP PERMIT SAR JowalN Cowry FJlvao►o®rrAL HEALTH DePARryaw 1868 EAST HAmTON AvaNlE - STocKrom CA 95205.6232 (209) 46&3420 FYPIRFS 4 YFArt FRAY DATF ISSUED 1 HEREEry CERTIFY THAT 1 HAVE PREPARED Tris APPUGA1 RJR Amu 1 r ' , re — — — — �- -- - - - JOAQUN N COUNTY ORDANCM STATE LAWS, AND RULES AND REb1AAT1O1N5- I ALSO CEiCTFY THAT n ii1D r R£MCENSE IS CURRENT AND ACTIVE WITH THE CAI.FORWA CONTRACTOM STATE rJCE3SE BOARD AND THAT I AN IN C11IL71AlICE WTH ALL WORKERS COMPENSATION LAWS. IMUM R ADVAkCE �iOTF-E REGU RED FOR iNSr EC:TIONS - PLEASE om C' z'- lt'v]v`_./' , 7irtF �M 0-C t� D&TE LAM r(r 044 )I RE YMFN cE��F�T QU/N c l pqR� L ry T 7-� DEPARTMENT USE ONLY Application Accepted By ��`- Daft Area -1 % / E--Vr-' IDs Fri;f)^ Grout Inspection By Date _ SPECIAL Well Permit Pump Inspection By Date it _Z _ WAIVER ReeetVed Soil Boring inspection By Date Constructed Well Depth It COMMENTS IJe-j Well r n.,J N/f:%0 gd,?91 EnD. /3S- 7Z 2-3 - - - Jon ADDRESS u� cTTYrADDRESS �n1 y'�' APN li ( J ^ Vh PArtcSr+��_Luo U.E Avrut�.w^�ow�nA CROs STREET r % a OWNERNAME /C rr N� j C� 1'",t 1 �_F' I1l4+e TR p � PHONE -` v'IT p I OWNER ADDRESS C, I`� CtYISTATEWP CONTRACTOR S PHONE .w r n CoK ACTOR ADDREss CITYMATFIZP � SUBCONTRACTORrCOMSMTANT PROW SUSCOMTRACToR/CoNsuLTmTADDRESS QTY/STATErZF Nine%.% 'j7 1 ExPr .IDATe `i- �y'- ! ��•` LICENSE ❑ G-57 Yr 61 C D-09 D Other ,7 BdLllw PARTY. J OWNER D CONTRACTOR ❑ TANT DOMESTIc WELL SmPLLNGi u General Mineral/Coliform Bacteria (4391) u Dibromochloropropane (4392) u Arsenic (4393) INTENDED USE )s DomestiorPrivate, C Irrigation/Agriailhnal C Industrial D Water Quality Monitoring O Sol Tion F1 Public watersystem - carwn � or Pt o Horan e otrmarr eon on,.r. ,� system Harte TYPE OF Worm X New Well i i Replacement Wei i Wei ABerationlModi6ration I Other i i Monitoring Well(s) tt of Weis I Son Boring(s) 9 or bolts i Geotechnical * of torte 1 1 Out -Of -Service Well r i Ou"WService Well Reneger I n Cross -Connection Repair r l New Purnp 1 1 Pump Replacement I I Pump Repair I I Rase Wei Casing WELL CONSTRUCTION f I t 1 Cable Tod I I Push Paint I I Other Drilling Method I I Mud Rotary I Air Rotary Auger Proposed Wag Depth ft Excavation in diameter 3 Open Bottom ❑ Gravel PaddGravel See in diameter C Conductor Caseeg in diameter / Conductor Casng Depth ft Wen Casing Dremeter _ in ThldmessJGa,rgdASTM Sired -' Sted ❑ Plastic C Stainless Steel -- Other Grout Seal Depth R n Neat Cement (94 R) bag/5-10 gal wafer) n Sand Cement sack mird7 gal ,rater I I Bentonite (20% solids) I Other Grout Piaament Medwil D Pumped ❑ Free Fail D Otter C Retardant/ Acceierabar (nar>e) PmESTAL Installed By 2 DOW C Pump Contractor = Other ft Tuck in Christy Bax Sieve ripe I Concrete Pedestal ! Danensions: WKM ft Lenge, a d 4 lvr,arc?,Iv - Turhe,e - Ottner h� Ftms Sg A Siandr5 Y,taea Le+Fi It 1 HEREEry CERTIFY THAT 1 HAVE PREPARED Tris APPUGA1 RJR Amu 1 r ' , re — — — — �- -- - - - JOAQUN N COUNTY ORDANCM STATE LAWS, AND RULES AND REb1AAT1O1N5- I ALSO CEiCTFY THAT n ii1D r R£MCENSE IS CURRENT AND ACTIVE WITH THE CAI.FORWA CONTRACTOM STATE rJCE3SE BOARD AND THAT I AN IN C11IL71AlICE WTH ALL WORKERS COMPENSATION LAWS. IMUM R ADVAkCE �iOTF-E REGU RED FOR iNSr EC:TIONS - PLEASE om C' z'- lt'v]v`_./' , 7irtF �M 0-C t� D&TE LAM r(r 044 )I RE YMFN cE��F�T QU/N c l pqR� L ry T 7-� DEPARTMENT USE ONLY Application Accepted By ��`- Daft Area -1 % / E--Vr-' IDs Fri;f)^ Grout Inspection By Date _ SPECIAL Well Permit Pump Inspection By Date it _Z _ WAIVER ReeetVed Soil Boring inspection By Date Constructed Well Depth It COMMENTS IJe-j Well r n.,J N/f:%0 gd,?91 EnD. /3S- 7Z 2-3 - - -