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tiVELLIPURflP PERMIT <br /> SAN JoAaWN CouIJT`ENVIRONMENTAL HEAL DEPTL� / - 1868 East Hazolton Avenue-STOCICTON CA 95205-6232-(209)468.3420 <br /> NON-REFUNDABLE PERMIT ALL 9 953-7897 FOR Ifq:-rEGTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS rrC f ClTYIZlP � r y• <br /> CROSS STREET ` 4f r APN�J s — ZO "�PARCEL SR S -' �AN0 USE A PucnnoN a I m <br /> OWNER NAME ~ -, .>`. PHONE. <br /> ' OWNER ADDRESS J ` CITVISTATEIZIP IV �,�+t <br /> it PHONE 7 �{ <br /> CONTRACTOR - _ <br /> h� �) '' <br /> ' CONTRACTOR ADDRESS CITY/STATFJLP <br /> SUBCONTRACTOR r PHONE <br /> SUBCONTRACTOR ADDRESS ,,4 CITYISTATE/Z1P ' <br /> LICENSE '-67 I X61 I D-09 I Other NUMBE r EXPIRATION DATE <br /> GEOGRAPHICALiNFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE j�bomestirJPrivate Irrigation/Agricultural V Industrial Water Quality Monitoring Soil SamplinglCltaracterization <br /> Public WaterSystem nTAfor5 sinm ame <br /> ' Irdidarent from Oimor. y. ar,;n,, aaie or nna um ar <br /> TYPE OF WORNew Well Replacement Well I Well Alteration/Modification I Other <br /> ,�-.-• a of WOOS Geatechnical 'li nt lrodnyc <br /> (0onitoring Well(s) M of Tells I Sail Boring(s) <br /> Out-Or-Service Well I Out-Of-Service Well Renewal i Cross-Connection Repair <br /> ' -Vew Pump : Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x1viud Ro qt Air Rotary Auger i,Gable Tool ,Push Point Other <br /> Proposed Well'Depth �'(� It Excavation in diameter Open Bottom Gravel PaclC/Gravel S'ue in diameter <br /> Conductor.Casing in diameter / Conductor Casing Depth ft <br /> ' Wall Casing Diameter in Thiclmess/GaugeI.4STM Sched I Steel Plastic Stainless Steel I. Other <br /> GroutSeat Dept] c7Y'i <br /> It i Neat Cement(94 Ib bag/5 10 gal water) (Send Cement ✓ Tsacic nuxl7 galwater <br /> Bentonite(20%solids) J Other <br /> Grout Placement Method i umped a Free Fall i!Other Retardant/Accelerator(name) <br /> ' PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete P destmt DimensionsalVdth R Length k Thick m Christy Bou I"Stove Pipe <br /> y ft Standing Water Level % R I nl <br /> Purip LSubmersibleLl Turbine a Other HP Pump Set / d I <br /> f HEREBY CER7IFY 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 TWAT J AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> ,fi li Idl. OUR ADVANCE NOTICE EgUIR O FO1' ( f <br /> ,rr V <br /> SIGNED .�✓'/ '(- TITLE O DATE <br /> / �. <br /> 9 r <br /> E � <br /> 3q - <br /> " .x�rrraJ. <br /> A0 <br /> f <br /> v DEPARTMENT USE ONLY <br /> >' ale AreA Employee 04, S ��APPIGrout Accepted By _ � bate � SPECIAL Well Permit <br /> Grout inspection , <br /> Date WAIVER Received <br /> Pump inspection <br /> ' Date Constructed Well Depth It <br /> Soil Baring Inspection By � y(_� OF <br /> CO�IAMENTS (ivc'i•�-- i7� /u GT r�J .(JG >f'L.. <'-`' <br /> �.11W �., its _ h 41-1' <br /> : <br /> PE SC Received Check#/ Amount Dau PermtU Invoice# Well IDM <br /> ' Codes Info B Cash Remitted Service Re nest t <br /> JaiU ���� <br /> D _ <br /> ' WELL RUMP PERMIT <br /> ara4la5 <br />