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Page I of I <br /> NnNJOAQLINCrn,NT't F"VIRON.NIENTAI,HFALTUDEPARTNiWt.NI ELL PUMP PERMIT 304E WEBER <br /> NON-REFUNDABLE PERMIT' CALL (209) 953-7697 rOR INSPFCTIONS <br /> JOB ADDRESS 8372 S . JACK TONE RD . <br /> CITI/ZIP <br /> CROSS STREET FRENCH CAMP / R I ik, 183 -080-05 PARCEL SIZE 10- Sl <br /> tA 1 /m A—P o <br /> OWNER NAME PACIFIC SOUTHWEST IRRIGATION CORP : <br /> OWNER ADDILESS .P . O. BOX 31330 <br /> CITI'/,STATFJZII <br /> CONTRACTOR HENNINGS BROS . DRILLING CO , INC . <br /> CONTRACTOR ADDRESS 3525 P E L A N D A L E AVE . CITV/STATT/ZI1 <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS Crn'1STATE1ZI1 <br /> LICENSE M'-57 0 C-61 OD-09 0 other NUMBER 290813 <br /> C40GRAPIR(ALINFORMATION: Coordinates X Y To <br /> 11Domcstrc;Pn%akc 0 Irrigation/Agricultural 13 Industrial 13 Water Quality M <br /> 0 Public Water S"tern <br /> If differtm from 6.ner, <br /> TYPE OFWORK EX New Well 0 Replacement Well 13 Well Alteration/Modification 0 Test Hol <br /> 0 Monitoring Well(s) 4 04,wel Is 0 Soi I Bon ng(s) #of borings; <br /> 0 Well Destruction 0 Out-Ot,Service well 0 Out-Of- <br /> 0 Nein Pump 0 Pump Replacement O.Purim Repair 0 Crosis-C, <br /> VV ELL CONSTRU(,`TJON <br /> Drilling Method (X Mud Rotary 13 Air Rotary 0 Auger 1:1 Cable Tool 0 Push Per <br /> Proposed Well Depth fl Excavation-1o <br /> -A.—in diameter 0 Open Bottom <br /> Conductor Casing Depth <br /> Well Casing Diameter in Thickrrcss/GaugeIASTM Sched <br /> tfjj0_Cj_ 0 Sit-el <br /> cxplaslic <br /> Crout Seal Depth 10 7&k A 0 Neal Cement (94 1h hag/3-10gal water} 0 Sand Cc <br /> Ix fientonite(2011N. solids) 0 Manufacturer Spec%solids % Name <br /> Grout Placement Method EX Pumped 0 Free mall Cl Other 0 Retardant I Acce <br /> PEDESTAL Installed By El Driller )UPUMP Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: Width_ ft Length ft Thick <br /> iptmp 0 Submersible 0 "I'Llihme 0 Other lip Pump Set <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' THE WORK WI <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO C <br /> CURRENT AND ACTI\ r WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AN <br /> WORKERSCOMPENSATION ION LAWS. <br /> %1ININIt \1 24 HOUR ADVANCEo*rICE REQUIRED FOR <br /> S U P E R V I S 0 R <br /> 1 14 1 1 1 1 TT-T -1 I I I I I , I I I I T_T_J I a1tc <br /> file:RCADocuments and SettingskountertwoTocal Se1tings\Temp\DMC1\D00\1.JPG 9/18/2012 <br />