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Tr Gl.L I r veli rZIuvll l <br /> NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JW E WEBER AVE Y°FL-STOCRTON CA 9$202 -(209)4a-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-:77699Z7LE011,11NISPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSSTREET L <br /> � 6/ CIrY/ZIP�(i <br /> CROV <br /> SS ( 1 Mi g <br /> ^'L �PN� �D PARCEL$IZEAND USE APPLIGTIONp <br /> OWNER NAME Vti rn�`lD/1r / /I-- PHONE <br /> OWNERADDRE2S X <br /> CfTY/SI'ATE21P � /L rE <br /> CONTRACTOR PHONE X62 <br /> CDNRACroRADDRCSB -7-1 WAle <br /> CITY/$TATE/ZIP Si/Yc _/, <br /> $UBCONBACTOR PHONE <br /> SU000NRACEORADD1UEA9 CRY/STATEIZIP <br /> LICENSE C-$7 E3 C-61 0699 pother NUMBER I, IIRATIONDAT6 <br /> GEOGRAPHICALINPORMATION: Coundlmita X V Township_ Rnnge_ Satin <br /> INTENDEDUSE ICDomestic/Ppvne pinigeliDNAgriculmral E3 Industrial E3 huQuality Monitoring psoil Sam0ling/Charactedzation <br /> p Public Water S star <br /> Halffemn rrvm Av Mr _ -me Doan emelt rc u r <br /> TYPE OF WORK p New Well El Reptaccmant Well O Well Altemtimn/Modifiation Cl Test Hole p Other <br /> O Monitoring Wells)_p of well, OSoil Boring(s) "EON,p, 0Geowhiical sorewinp <br /> O Well Destruction O Out-0f-Service Well ❑Out-Of-Service Well Renewal <br /> O New Pump LkPaMpR hicanem O Pum R it O CnmComnation Repair <br /> WELLCONWRUCr1ON <br /> Drilling Method O Mud Bounty Cl Air Rotary ❑At p Cable Tool p Push Point O Other <br /> Proposed Well Depth ft Excavation indiemeter OOpen Bottom 13 Gravel Peck/Gravel Si.-m diameter <br /> OConducmr Casing mdiamem / Cond.UVCasing Depth ft <br /> Well Catalog Diameter_in Thiekness/Gauga/ASTM Sched O Stal O Plastic O Stain on,Slcel ❑other <br /> Grout Sal Depth ft O Nat Cement(94 In peg/3-Toga/warm) El Sand Cement sack raiz/7 gal weer <br /> p Bentonite(21P.solid.) O ManufMp m Spa%solid. % Name U Specs on File ❑Spas Submitted <br /> Grout Placement Method O Pumped O Free Fell p Other O ReMrdant/Accelerator(name) <br /> PEDESrAL Installed By 0Ddlier OPump Contractor ❑Other <br /> O w <br /> Concrete Pedel Dimensions: Width_ R Ungth ft Thick in O Christy Boa ❑Sieve Pipe <br /> PUMP 74 Submersible 13 Turbine ❑Other HP Pump Set ft Standing Water Level Fl <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 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU H7R ADVANCE NOTICEp^/ren/�UIRED FOR INSPECTIONS <br /> sIGNPD / TITLE i/ YG/ DATE <br /> 1 1111114 <br /> Gu <br /> N E <br /> E <br /> G <br /> TM ENT USE /N LY <br /> Application Accepted By 3�{T—� Date J p� —E p —1pR <br /> Grout Inspection By Dote ❑ SPECIAL Well Permit <br /> ft.,lnspeeuon .. para / E3 WAIVER Received <br /> T1fT— <br /> Usuumm.hapecotion By DataG Constructed Wahl Depth ft <br /> COMMENTS <br /> PE SC Realved Amount bee PermW Iom1aN WeII IDN <br /> Cuda IR(o B ash Remitted SerHaR uatN <br /> S W 9 1 <br /> ENO{}03NM1 WELLPtMPPERWT <br /> Pin4 <br />