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IF <br /> r,.'AL6%1SLAl q—W-Oyu <br /> WELL/PUMP PERMIT <br /> SAN JOAOUN COUNTY ENNRONMENTAL HEALTH DEPAR111M 1868 EA57 HA LYON AMUE-SMMWN CA 95205-(209)469$020 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB AooReaa � t�d IcRrmP QG' <br /> �1 MI 9 <br /> I5��0 <br /> CRM STREET V� Tll)C.V� I['J I/7' APN I U PARCEL SBF jL_C, LAND USE MPUGTOM0 <br /> OMER NAME I\L V V V)I PHONE��q— <br /> OWNER ADDRESS SG MP. C"ISTATE/Z1P <br /> CONTIMCTOR PHONE 36cit —277q <br /> CONTRACTOR AOCRE99 P. c 9v'A CRY/STATE/Z1P L IQ. CA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADOUN CC�RYISTATEMP <br /> LICENSE C-57 f C 61 D-09 L Other NUM6E ,XI1 4 EvolumoN DATE - -' <br /> GEOGRAPHICAL INFORMATION: Coordinates% y TOWnshlp_ Range Section_ <br /> INrENpap UaE ;w"Dornestic/Prorete n a rtgaftniAgdaltrnl ]Indusblal o Water-Quality MOnkoMg J Soil Samping/Charact cion <br /> r` lTPuobliMat�01r star �.112.11. mRPr nefer <br /> TYPE OF WoEx >LNew Well ReplacmNmt Well C ANSI AlteraWnModkiration o Diner <br /> o Monitoring Wells) Sof Wella C Sod Borings) smmneps L Geotechnical *oboes <br /> n Out-Of-Service Well F Old-Of-Service Well Renexal n Cross-Connec ion Repair <br /> New Pump n Pump Replacement C Pump Repair O Raise WNI Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary "Auger 'Cable TOB r Push Point - Oth <br /> Proposed Well Depth�R Excavation I in diameter n Open Boom )(Crawl PBck/GmVal Sae ')4_ in diameter <br /> _:Conductor Casing in diameter / Conductor Casing Depth fl <br /> Wall Casing DiameurCIL in Thnkness/Gauge/ASTM Sched -'A r9Y 7 Steel%Plastic C Stsinleas Slael C Omar <br /> Grout Seal Depth lrn It '!Neel Cement(94It,bag/610 98/hater) )t.Sand Cement 10.E sack mdn Bal veader <br /> U Bentonite(20%Solids) Other <br /> Grout Placement Mathotl Pumped 'J Free Fed J Other 'J Retardard/A.crelentar(nmx) <br /> PEDESTAL I lie By hl" Pump Contacts _ Other <br /> m%w liz"Ihl':DMansions:Width R <br /> VLmgItThick in rl Chrbty Boa in Stow PlPa <br /> 6ubmenible"Turbine -Other HP1 Pump Set it Stanto WWrLevel R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD ANO THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 24 HOU/R)ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963.7697 <br /> SIGNED GrPY'T(1lVVY/" TILE \! ICC I7YCSr c,C v1� DATE I IG <br /> c <br /> TY <br /> L <br /> H E NT <br /> O P TM <br /> ENT U E ONLY <br /> Application AaapWd By Data ) / Area Employee 10< ! <br /> Grout Inspection By om 0 SPECIAL W9I1 PertRit <br /> Pump Inspemon By Date J WAIVER Reeelved <br /> Soil Boring Inspection By Data Construcbd Well Depth R <br /> COMMENTS <br /> PE BC Retched Chattel Amount NTrnHI Invokes WeII IDR <br /> Codes Info CBM Remkbd Data Serves usete <br /> 8 e a� .�q rens Uo � <br /> I 5 <br /> I <br /> wTtumuMP PERurt <br /> E <br /> M]WT2 12 <br />