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WELL/PUMP PERMIT <br /> SAN JOAQUN COU!ITv E•NVIRCNMFNTAL HEALTH DEPARTMENT '868 EAST HAZEL Toh AVENUE.StxKToN CA 95205-6212 1209)468-1420 <br /> NON-REFUNDABLE PERMIT 1 ./Ww)W,.sjgov.org/ohd __ EX/PIIR__ES 1 YEAR FROM D!!lA111TE ISSUED <br /> IJosAoDRe3s 13g5G—i.�tY�Q SSL�L/'�cGi{MCA,-i/r� --CIT•alp Lt <br /> CROSS S.REET!_ APN O"'37.pCoog PARCELSIZE 4.8 LAND USE'AAP(PUUCCATION N �Q <br /> DINNER NAME r 1 �4�(�/1� _ _ I PPwo.,��V\E' IR a V-tS <br /> f OVMERADaarn3 l .t ` I GTYISTATERIP L QiI[ ,L-7 ctto,4 <br /> CONTRACTOR wc�-� PHONE (QCg,`LN--5;)L D <br /> CONTRACTOR AooaEss CCSZ Jo u1 j_U�(._�_c{ GTviSTATE,av --JDC+d"_L{ 644 <br /> SURCONTRACTOWCONSULTAN1 / ^ PHONE <br /> SUBCONTRACTOs/CONSULTANT ADDRESS ISTATE,ZIP <br /> I LICENSE ,[�57 C-61 D-U9 Other NUMBER ErPIRATIONDATE <br /> BILLING PARTV::v_ _ OWNER _ CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPUNG: General M neral!Cotlform Bacteria(4391) Diuror"ocnlo{oprooane(4392) Arsenic(4383) <br /> LNrENOED USE UumaLuuPnvale Imgation'Agncullural Industrial Water pualdy Monitoring Sod Sampkng/Characienzation <br /> Pub6C Vlater System _ <br /> n atknri 1,m O+Y,er W41a 9retan Name GantaC Name a,Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AneralionlModificatidn Other <br /> Monitoring We1(s1— S at weft Sod Boring(s) 0 of eunnps Geolechmcal N of Bongs <br /> Out-01-Service bYell Out-01-Service Well Renewal Crass-Connection Repair <br /> New Pump If Pump Replacement_ Pump Repau Raise-Well Cawrig p <br /> WELL CONITRUCTON - _ _- _.. RAy�PAY� �T <br /> Dnihng Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other_ <br /> Proposed Wen Dept'—fl. Excavation ir diameter Open Bottom Gravel Pack/Gravel Size m diameter <br /> Conductor Casing in diameter r Conductor CawN Deoth It <br /> Well Casing O,aineler in Thickness,Gauge/ASTM SChcd Steel PIasOC Slainlem Steel Other Se A, <br /> Grout Seal Depth It Meal Cement(94)D t>ao-10 oat waterl Sand Cement SaCPm„— / .1N <br /> gal ry�OAQU <br /> Bentarde(20%sohdc Otrw_ y� V/ (N C <br /> T RNIHEIV <br /> Grout Placement Method Pumped Free Fall other OWN Other Retardant I Accelerator(name; r H AD <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> _Concrete Pedestal Dimensions:Width_tt Length n Thick Christy Box Stove Pipe _ <br /> ,,PUMP �Su"_nuble Turbine Odie! --�- HP__ Pump Set (I Slaldw,Vvatc <br /> I HEREBY CEAFY 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 W17H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM ENSATION LAWS. <br /> Iiupr, c"R IN ' ECTIONR Pt EASE CALL(209)953 <br /> SIGNED IITLFaif� DATE Z- "� <br /> I <br /> 1 1 1 1 It <br /> I I <br /> I <br /> I <br /> l DEPARTMENT <br /> fUS O'NLY <br /> Appilcaban Accepted By �f� Date (I J Od0 A•ea mpinyeR IDS F <br /> GMUi InSpWion By n Dale SPECIAL W011 PArmit <br /> Pump Inspectwn By� �(�t�/lUi4 M4r't_ Date 1i111JP-U— WAIVER RGceived <br /> SGA Boning Inspection By Dale_- Constructed Well Depth tt <br /> COMMENTS <br /> PE SC I Received Check Amount Dorm Parmitj Invoice N Vfto IDR <br /> Codes Into Remitted rvice Re uost S' <br /> L439 10'1_0 7 <br /> FI,1n,j.QG GlriM,O -�" - WELL"Jl CAVn <br />