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is , <br />J <br />WELL/PUMP PERMIT <br />SAW JOAQ4- Coni" EwvaloNufmT&L HEALTH DF►Aorwo,T 1564 EAsT HAIEtTo" AvEWAE • ST COTON CA 95205 - (209) 4ti"20 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECT*NS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADoaESS _A vt &')v -1P CrTr?y T V 1w! iTe Cr <br />CROSS S1AE[1 i,/q j1 1 S '&LIr-L�SiS. �On L <br />L. �N .1 AMCFI K <br />�W �6 'DS4E 9 LAND USE AMiATgN 0 ._ a <br />OWNER NAM[ FRH Realty LLJC_— P-oME 858.414.6341 <br />O—ER ADORES$ 5355 Mira Sorrento Place, Suite 100 C,T,;STAr[IL9 San Diego, CA 92121 <br />CONTRACTOR GN(M C' L' �{��' �`",,n`(� �AJI""Py► L,-,,. (`P,�HO\NE I_ qz)�l -tfs S <br />CONTRACTOR ADDRESS { � C,O LOLii�\ [ CM[STATE/ZIP LA t r T -,e . /C�l� �p 3U .p <br />SUBCONTRACTOR C7� L�. �SW� V 1� Q C+X rA7i1U PHONE <br />SUBCONTRACTOR ADDRESS kSllo Ma•Ak F'0. 0 ri VC CIPIISTATEIZIP_rk XO✓),C^) 11510ZLi <br />I <br />IUCENSE k C-57 C -6t 0-09 Ocher NuMBEA QS5 ExPtAAT10N DATE <br />L. <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bactena (4391) Dlbromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Oomesbc/Pnvate Imgation/Agncultural Industrial Water Quality Monitoring Sal Sampling/Charaaenzabon <br />Public Water System <br />N onerely f cm ow s' Wzw System Name Conrad Nartr or Phcne NL"lkw <br />TYPE OF WORK New Well Replacement Well Well Allerat:on/Modification <br />Monitoring Wells) 9 of wells )(Soil Bonng(s) i— <br />Out-Of-Service Well Out -Of -Service Well Renew, <br />Other <br />r or I alms Geotechnical <br />1 Cross -Connection Repair <br />Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool )I' Push Point Other <br />Proposed Well Depth_ it Excavation Z in diameter Open Bottom Gravel Pack/Gravel S¢t <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameler _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Grout Seal Depth CQ <br />_it ,k' Neat Cement (94 to bagi5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped It Free Fall Other Retardant I Accelerator (name) <br />(PEDESTAL Installed By Driller Pump Contractor Other <br />�— Concrete Pedestal -Dimensions: Width it Length It Thick �S„ <br />n Christy Box Stove Pipe ]r p r <br />PUMP Submersible Turbine Other HP_ Pump Set_ it Standing Water Level ��6vle6l <br />Plot flan Requirements: Attach a plot plan with the exact location of water well with respect to the following �jjy�: e)I'S <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing stcll4l1[ti'� ,. <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property ling4or Domesficl�? <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius or proposed IlUQ�fNCO <br />NII\INl %124 1100 R l NO I V I urt)t mit) l uR I 11S9 - I'LL 1St. L ki.L 1'0919.3.7697 �EDMENr r' <br />•dbw-p <br />in diameter <br />Other <br />sack mix/7 gal water <br />DEPARTMENT USE ONLY <br />Application Accepted By Dale �S� a Area "! Employee IDr: 1�1 <br />Grout Inspection By Dale _ SPECIAL Well Permit <br />Pump Inspection By 4. J Date WAIVER Received <br />Soil Boring Inspection By Date Jr Z 5.i Constructed Well Depth ft <br />COMMENTS f l? Pp; rir Qra/J»CJ',.1a e -r JS lonc.w71fer2 <br />I 11D.1 1. 117'111 1021 <br />M <br />Nall, I.—V P.M. <br />rz K.011 <br />I 11D.1 1. 117'111 1021 <br />M <br />Nall, I.—V P.M. <br />