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IIA" WELUPUMP PERMIT <br /> i SAN.)OACULRCot1NTy ENVIRCNMENTAL I'IEALT.-. PARTMIENT 600 EASY MAIN STREET-S..-.-.-TOM CrA9$202•(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION$ EXPIRES 1 YEAR F TE ISSUED <br /> JOB ADDRESSwow -f CnylZIP <br /> cRDss$TREEr APN I'T�-,I `�PARCEL SIZE LANDUVffLgf,%&n5jG <br /> ^U t'tf} lur' <br /> OWNERNAME T L�r PHONE <br /> OWIrERADORESS f� -V CITYISTaTFJ-LLP J� <br /> CONTRACTOR LL/ PHONE ZD Q v <br /> CONTRACTOR ADDRESS w CIT11STATPIZIP� <br /> SUBCONTRACTOR PHONE 41fo' 362.9rsAII <br /> SUBCONTRACTOR ADDRESS �4+ 7RsIDI LG Xcwp L/+g`✓�`Z-3IrT1STATEIZIP � IGr'iV77�EMr4-�+ ?Z <br /> LICENSE -57 0 C-61 0 D-09 ❑Other NUMBER OC67a IG_ EnnItAnm DATE <br /> GEOGRAPHICALINFORMATION: Coordinate6X S O.3Z Y p_ Range Section <br /> TEN SE ❑bomesdclPrivate G InigatloNAgricultural 0 Industrial ❑Water Quality Morilloring Sail SamplinglCharacterizabon <br /> ❑Public Water System L dA V <br /> . If ELMMIM from Owren. '�7TwA?fT$yakem tirrq - grnp Or n¢Nufftw <br /> I <br /> 3�211IOFVORK ❑New Well n Replacement Well ❑�pfelI Atteratlor Modifltation ❑Other <br /> techntcal <br /> i � DMtaA #oreonrms <br /> ❑Monitoring Well(S) #of wells Sal Horing(s)�� <br /> f 0 Out-Of-Service Well 0 Out-Of-Servioe Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement 0 PumR Repair <br /> t!i eLL CONSTr:ucnoN <br /> i <br /> Drilling Method 0 Mud Rotary ❑Air Rotary Vxuger !]Gable Tod b Push Point ❑ Other <br /> Pupeser3 dell DB th O _f1 Excavation h in diameter ❑Open Bottom ❑Gravel PaddGravel Size in diameter <br /> ❑Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Ciding Oiameter—in Thickna"sl LgelASTM Sched O StaeL 0 Plastic n Stainless Steel 0 Other <br /> Grout Seal Depth R VNeat Cement M 1b bag/5-1 U go/watsO ❑Sand Cement sackn;W7 gal water <br /> 0 l3entonite(20%solids) ❑Other <br /> Grout Placement Method to Pumped O Free Fall ❑Other nt I r(name) <br /> PEDE$TAI I Iled By 0 Driller 0 Pump Contractor 0 Other <br /> /AVpncrete Pedesta)Dimensions:Width It Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> ffiW-MPersible❑Turbine 0 Other HP Pump Set .. ft� Standing Water Level ft <br /> I HEREBY CERTOY NAT I HAVE PIQEPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE. IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MUM 24 HOUR ADVANCE NOTICE ftEOUIREII.FOR INSPECTIONS <br /> SIGNED TITLE / DATE IZ&_CR <br /> 1 <br /> LOT 1j1&7.fTI0II) SEE <br /> DETAIL' a. <br /> i I 9 <br /> ?r 4� <br /> IiI` I <br /> MAI <br /> A.P.N. 179�100�t1 1 III <br /> f Lsu <br /> — I . <br /> ME <br /> LSNTORD AVE. ° 1OD-+• i <br /> D,,E P AA..T,M-E_N._U_e.E_ .O Y om, ...,. --...�—• -�+-^ <br /> ' Application Acoe4ted$ Date v l Area Employee ID# <br /> Grout Inspection Data ❑ SPECIAL Well Permit 1 <br /> Pump Inspection B Date d WAIVER RGCelvGd I <br /> ( Soil Boring In action Date Z l Constructed Well Depth R <br /> CO NTS i <br /> c.` o �s <br /> I PE se Received Amount Date Permtl Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Request 0 <br /> Vt .5p 00589(7 <br /> . Gez <br /> I s <br /> EHD 43-06 WELL!PUMP PERMIT <br /> 111E V211'07 <br /> I <br />