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Address: 21711 Cherry Glen Ct <br />ID: WP0041637 <br />_'" JOAQUIN COONENVIRON <br />NON TV MENTAL HE W <br />'REl`UNDABLS HEALTH <br />DEPARTI4ENELL�P�MPP 116(A <br />PERMIT <br />JOe ADD ERM, <br />l� Z'2' <br />RE68 L I I , <br />WWW EWi CA 96105 -82721209)188-3420 <br />•� /� 1 <br />8 Ohe <br />CROS& OV, HSttI.TON AVENUE-6TOCIRON <br />STREET - �- 18hd YEAR FROM DATE ISSUED <br />- <br />C/7 <br />�Nli tirl. EXPIRES 1 <br />N <br />OWNER /' <br />NAME r lAPN <br />C+D(�j CITV/LP '^� EIS <br />� <br />'7 7/- <br />s �J //` l✓C/�/ <br />,`'y�p7 <br />OWNER ADDRE9& �� OrL /(',-� p4kgSlZe� LAND USE APPLICATIONM <br />USE <br />✓ ) <br />CONTRACTOR PHONE <br />�gmi/-��T f� /�+ <br />s lCONTRACTOR ADDRESS DITIBrArEZP <br />J G C- / ya <br />� <br />PHONE 53Y' <br />SUBCONT RACTORICONSULTANT <br />6DBDONT <br />L-3 <br />RACTORICONSULTANTADDRE99PHONE <br />LICENSE <br />-57 ❑ C -81D <br />y 9UtBILLING <br />D-0-.TAI.P <br />� <br />PAROther �3_ <br />ER � NUNaBt ,{17 s•)S EI(PIMTION DATE <br />r' CONTRACTOR <br />DOMESTIC <br />11 SUBCONTA <br />WELL SAMpu"0i�coNsuLUHT <br />Np; General <br />MlnereUCDli(orm Bacteria (g3gT <br />INTENDED USE' ) Dib pr <br />DomealinJpdYete D IrrlgelloNAgricu8ural U Industrial �O °)ane (4392) O Arsenic (4383) <br />�j I/rJ/1 <br />r <br />❑PublicWater System nWatINO <br />S n dmerenl tram Ow.lar: uOR/Monilorirg o son semvllnycnar.derlselron <br />­_9Yslem Name CUMM Namea Phar lWmeer <br />TYP OF OPlaw Well D Repiecemenl <br />5—,L� LI 7" sxf <br />Well <br />9 U Well /ModiBcalion U❑Other <br />U MonWells) <br />1 o(wells U Soil Bon nrg,lu <br />D OutOf-Siervice Well s) '0 1' Yp1a0d"a' <br />D Gotechnical <br />Z�JS- <br />ew Pum❑ Pum DOul-Of-SeNiceWenRenwal (ICoConecoRepair <br />Relaosment ❑ Pu <br />ZWELL <br />CONSTRUCTION Well Cai <br />Drilling Method C,.MUd Rotary ❑ Air Rotary ❑ Auger U Cable Tool ❑ Push Point ❑ Other <br />7— <br />Proposed Well Depth -�-uT q Excavation I2 in diameler ❑ Open Bottom PFGrovel PeOWGravel She In dlameter <br />-T <br />I1Conductor Caeln9 In dlemeter I Conductor Casing Dep(h S <br />Well Casing Diameter ri In ThickneSSIGaugalASTM SC❑Stainless Steel U Other <br />hed 100 D Steel Ii "'7 steel <br />� <br />^ 6 2. <br />���' - 1• <br />Grout Seat Depth / del N ❑ Neel Camenl (941b beg/5-IOgelwele0 @'Bend Cement sack mnR gal water <br />Sane <br />2 -TT'"? - Z <br />❑ Bentonite [20% solids) ❑ Other <br />]!! <br />72-97- 7 <br />Grout Placement Method Pumped 11 Free Fell ❑Other O Retardant /Accelerator (name) <br />3 Q /� <br />'O <br />V ' Z -� 2y� 1 <br />PEDESTAL Installed By ,GCDriller ❑Pump COnlrOdor ❑ Other <br />installed <br />Pedestal ❑Dimensions: Width �S Length P 8 Th in ❑ Chdsty Bo: 13 St pip. <br />Pu Set A Sten0lrp Water Leval R <br />pump /S SubmarsibleO Turbine O Other HPC_ Pump <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE T ICIALSO CERTIFY THAT- BE DONE NMYOREQUIRED LI CORDANCE ENSEI aAIS <br />JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, <br />BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE <br />WORKERS COMPENSATION LAWS. I no.n FnR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />