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WELL/PUMP PERMIT <br />SAN JOAO= CouNrr EwwomfiwAL HEALTH DEPARTt®+T 1868 EAST HAZEL"N AVEM1E - STOCKMN CA 95205 -6= 1209146&3420 <br />NON-REFUNDABLE PERMfr wwwsjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS o (C) `I It L)J �S I -'I 15X11 /) .f CTTYrA p C. S C-r7'1'V.4P' I <br />CROSS STREET I n APN uc l7 _> l7 n d PARCEL SM 9 1 ] L AHn Usr APPLlunc;w it. <br />OWNER NAMEl-�c .`men C(. (l:,A,f 0 l? Phone <br />OWNER ADDRESS ((14en , 01. f CmH7B <br />ISfSTAT <br />CONTRACTOR , (/1 " P�NNONE <br />CONTRACTOR A..�_ it)ox\ l V'� C..TATEIZ. Q( t KrN�r1 \ Si <br />PHONE .201-1 /0 `1 <br />SUBCONTRACTOWCONSULTANT ADDRESS CTTYMTATEhZIP - <br />L.IcET4ISE 0 C-57 VC -61 C D-09 0 Other NuraER 57415 EMRATNDNDATE <br />B41NG PARTY: 7 OWNER C}L/NNTItACTOR u SUBCDNTRAGTOWCOIWILTANT <br />DomEsTTc WELL SAMPLING: u General Mineral/Coliform Bacteria (4391) u Dibromcchlompropane (4392) U Arsenic (4393) <br />INroNOED USE esbc/Private -1 IrNigationlAgricultural C Industrial 0 Water Quality Monitoring ❑ Soil Sampli g/Charactersation <br />n Public Water System <br />e ®ferakd b— Orewr. Vyamr Syshom Name Contad Nave or Phme Number <br />TYPE OF WORK i I New Well epiacagnent Wen I Wen Afleration/ModiFcation I Other <br />I I Monitoring Well(s) # of webs i Soil Boring(s) R w bw"a I Geotechnical <br />I I Out -Of -Service Well i i Out-0I41ervice Wen Renewal i i Cross -Connection Repair <br />!C New Pruni I i Pump Rentacement I I PumD Repair I I Raise Well Casing <br />Drilling Method I I Mud Rotary I Air Rotary I Auger I I Cade Tod i I Push Point I I Other dry <br />'Proposed Well Depth ft Excavation in diameter 7 Open Bottom ❑ Grave! PadJGtavel Size <br />u Conductor Casing in diameter f Conductor Casing Depth it L%I C)/V/ <br />Weil Casing Diameter in ThidmesslGaugeIASTM Srhed —--steel a Plastic 0 Stamlem Steel OUrer kir <br />Grout Seal Depth ft n Neat Cement (941b b111915-10 gal water) r Sand Cement sock rmx(r gal vrateer <br />iI Bentonite, (20%solids) I Other <br />Grout PLacerneat Method 7 Pumped 2 Free Fail --E] Other Retardant 1AccelPsalor (name) <br />PIDESTAL Instated By C Drill Conbad ( - Other e <br />Concrete Pedestal ' Denensions: Width � ft Length R Ttcik n Christy 13az Steve Pipe i <br />PUMP P-! `ub rtetsible - Turbine - Other `? Puri Set -,662—t sadtdrn Water ! we <br />1 07nFID <br />HERE13Y CY THAT 1 HAVE PREPARED TICS APPLICATION ATHAT THE VV0W WILL BE DOZE W ACCUFMA110E Wr4 SAIn <br />JOAQUIN COUNTY ORDQiANCM STATE LAWS, AND RULES AM TEGULATIDIS_ I ALSO CEI FY THAT NY ICT >- n eE39SE 8 <br />CURRENT AND ACTIVE WITH THE CALFORS" CONTRACTORS STATE t JCEXSE BOARD AND THAT I AM IN CC294-1 1I.E W t' ALL <br />WORKERS COMPENSATION LAMES. <br />IMUM R ADVANCE NC7IICE REQUfRED FOR NSPECTX)w - PLEASE CALL 12W 953- £S7 <br />'i OEM_ // -.2- zo Zi <br />DEPARTMENT USE ONLY <br />Application Accepted By F L- Da:e ) /L <br />Grout Inspection By Date <br />Pump Inspection ByCC0:21Date / ZA <br />Soil Boring Inspection By Date <br />COMMENTS� tJ 14 e r r I-'nI Uri :)L�r 193SC( <br />/PIED-cnup, Yy M IV -Prof <br />� aINW��F-Effm n <br />l Cf i �7 <br />Area �E�-�-me <br />PECUIL Well Permit <br />WArim Received <br />Constructed Well Depth ti <br />WHL RUMP PERMR <br />Q <br />X021 <br />N4I- <br />N <br />04 <br />