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WELL/PUMP PERMIT 1 <br /> SAY JOAQUINCOUNTY LWIRON.MENTALHI-.—HDEPART\IEa-r 304EWEEERAVE 3"Fr, rocKToN CA 95202-(209)469-3420 <br /> NON-REFUNDAB <br /> L <br /> LEFPERMIT �!CALL(2091 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED S <br /> JOR ADUREss I v��� �1 r i !.�'\l N� CIrVIZ[P h r o 'Al <br /> Citrlss S I'REL"1' h d tl ��7 E? / 1l7,[,r\[[1�1 y APN PARCELSME <br /> a OWNER NAME - rt } PHONE p <br /> Ots'NER.\DURESS .� alU '� CITYISTATE(xIP Z-c�/1vp 7Sally <br /> CONI-RAC-1'0K -�1 r�'[1—u ,L ter l'L �l --/PHONE <br /> CONI'R•1C'TORADvRt;ss��17`I 7� � C—+ fV�C?I/1� 41/P CIIVI-^!ISTATEIZIP n6i0o <br /> !_ <br /> SUBCONTRACTOR PHONE !V <br /> SuSCOSTRACT�ORR ADDRESS/� - • CMIST'ATFIZIP 1 <br /> LICENSE I9'57 0 C-61 0 D-09 O Othcr NVM8ER 0 EXPIRATION DATE VNe <br /> E CkDGWII[CAL iNPORStATION'I Coordinates X V Towmhlp 1p Ranze j� Sectlan�� <br /> IL I'Vr$NDE;D V$R M Domcstic/Privayy Cl_Irrig1ation/Agricultur1a!L M l slrial O Water Quellty lvi 'to ripn�g� (3 Soil Sampling/Chareyc riutlon <br /> I PI dllfftmm.al}arri Ow em t,tfrs /..'� Iru�.11r ]. rmriLl�e �� a"C rWcr Nrmem�+rcr+ � �Q <br /> TYPE OF WORK ew Welt,__. 0 Replacement Well O Well Alteration/Modification O Test Hole O Other <br /> P ni w'- nambero(wells ra.mber arbonags camber a[borings <br /> I �Mamtonng Wcll(s) ❑Soil Honng(s) ❑Geotechnical <br /> O Well I7estruclion 0 Out-O f-Service Weil O Out-OF-Service Wcll Renewal <br /> f O New Pum O Pump,Replacement O Purup Re air O Cross-Connection Re air <br /> WELL CONSTRUCTION � <br /> i Drilling Meth it ❑Mu<I 8atary ❑Air Rumry ZI Au'�r CI Cable TOwl O Pu.h Point BT]lhcr-Rey>°I'7 f •�0 r7 <br /> .pf Proposed Well Ihrpth_� -(+�_-- 11 I:xcnvnlion _--_in diameter CI Open Huuun+ ES(irnvcl Pack I Grn cl gibe in dium/cter <br /> ` II?<'onducwr('usingm dmmcler I ('.+I[dneLr avin I�c dr _Il 7. V v�Pf N1 14 C <br /> W01 Casing I Iimucicr l& _ r '131icknrs.i(iunµclA.ti'I'A1 5+:hcd 1 ,J_�[I' t811er1 ❑��h'''Instic O tilninlc.+Stec! d Other <br /> Gr.n.i Seal I)rpeh (,+ I Il 0 N-1['cmrnl(94 11.bah/s_!n gar wntr•r) fillnnd 4'cn.eue r r _., _ ua k mk 17 gni water <br /> l-roof 19arenu•nl Al rlhnt!'�ile`I itm��diJrp l;rc011iuulix.�.'i"Itiprr.".L v+[ids 'L Mune _ O Specs un FiW C3 Specs Submiued _ <br /> _ _ry O ltclanhurt l Accelennnr manse) <br /> PEDESTAL la etO Driller O I'IDp1jUntmdnr uOtherECaocrre <br /> Pedestal Dimensions: Width J- R Lcngt n Thick in O Christy Box O glove Pipe <br /> PUMP O Submemihle ❑'rurbine O Other_ HP Pump Set -R Standing Water Level R <br /> WELL DEsTRuCTIOY O Open Bottom ❑Gravel Pack 0 Uncased (3 Other <br /> Weil Diameter_in Total Depth it Depth 10 Water R 13 Casing to be Perforated from R to it <br /> Sealing Material O Neal Cement(94 lb bag/S-10gal+ tcr) O Sand Cement sack mix 17 gal water O Bentonite Pellets <br /> O Bemonite(20%solids) O Manufacturer Spec%solids % Name O Specs ort Fila ❑1Rp s Submitted„ <br /> Placement Method O Pumped O Free Fall O Other <br /> O Complete with Mushroom Cap ft below grade 0 Complete to EAisling Surface Pad - = <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 AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> _ MINIMUN(24 HOUR ADVANCE NOTICE REQI;IRF:D FOR INSPECTIONS <br /> SIGNED TITLE fY I TOtDATE �d ,n n(-1 <br /> I <br /> 1 Alk <br /> �,y �//s <br /> DEPIA R HE�TUE Y �39 <br /> Application Accep piow�, Dale Arca Employee IDI+Grout InspcctioI�t 44--*; ✓f [ - bate �" 13 SPECIAL Well Permit <br /> Pump Inspection By Date IJ WAIVER Received <br /> Destruction Inspection By Bate _ Constructed Well Depth <br /> �[4ENTs 1'+L�1 n . <br /> RWS <br /> PE SC Amount Chrch#! Received PermkU <br /> Cadea Infra Rcmltted cmdi' By Date Srrvler Request# Invoice# Weil[D# <br /> c,1 t.o <br /> EHD 43-02-006 Mister water Well Pcnait.dot <br /> 211412003 - <br />