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WELL / PUMP PERMIT
<br />
<br />itaratil DEPARFMENT NOE Vann' An S" Ft. • SwanON CA 9S2S2 • (299)4M-2420 !
<br />1 YEAR FROM DATE ISSUED
<br />ran. •1,1?"., r.a. • ••,....F -- -
<br />NON; UNDABLE PERMIT .
<br />. . , ''' ."'' ' "" ' ....* •,.. .., •• .
<br />
<br />Crn/Zir '.• , ,A.t.
<br />JOB ADDRESS L_C) el / ,os
<br />
<br />q..5'• 2-4
<br />1P A PS , it, 07- c St -2.14PARCEL SIZE -- LAND UsEAmJCATIOS„_ _........,
<br />Citosa Smarr _T)talildi:"..., ,,
<br />PHONE
<br />OWNER NAME TAze,-4,,ku Yiedefe4iti:41 _
<br />CITYISTATEJZIP fidalfleifa__.(1/f
<br />OWNER ADDRESS Z-=
<br />,
<br />.,._.--Jeelf-trill-
<br />.ConaAcrota
<br />CT, OtCrstA OR ADDRESS "PO / CrTY/STATErLIP __
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<br />IC
<br />.
<br />NONE
<br />SEINCONTRAMOR
<br />CITY/STATE/DP
<br />SUBCONTRACTOR ADDRESS
<br />.
<br />EXPIRATION DATE
<br />LICENSE e‘; DC-61 0 D-00 0 Cnner NUMBER _ _
<br />Township , Range Section
<br />IC IDDGRAPIISCAL INFORMATION: Coordinates V _
<br />1 DTEnDES UU 0 Domestic/Pr.vnte rrigation/Aglicultural 0 Industrial C Water Quality Monitoring 0 Sail Samplit*Ossescteriaation
<br />L
<br /> System ! 0 Ppit V./ter , c,„„.,,F.....,... N'arenr
<br />0 Other .,
<br />TM, Qt WORN Neyy Well III441ar,entera Well 0 Well AlteraMoMudification
<br />- ••••••!,40. 0 of weep * a
<br />0 Monitoring Well(s) 4 of wr11E 0 Soil 'Berie 0 Gto.uxAnicalg(s) _
<br />. ,
<br />, 0 Out-Of-Service Well 0 Out-Of-Service Weil Renewal 0 Ciess-Conrection Repair ..
<br />0 New Pump . 0 Pump ReplectInent C.l6sp Repnit
<br />MIL CoanTIWCDON et .
<br />0 Push PoiM 0 Other
<br />Defiant Method 0 Mud Rotary C Air Rotary 0 Auger ,, Tool _,../
<br />Prot:vied Will Depth '5496 It 1'7...mays . in diarnetex 10•6pen ike.Din 0 Gits,C1 PliCk / Caa*Vel Siit ' . in diameter
<br />0 Condoctor Colon in dianeter I Condumor Casing Depth 0 . . 0 Stainless Steel 0 0 ef
<br />Well Casing Diameter ., in ThceessiGauge+ASTM Sched . 721/1
<br />Neat Cement lb hag / 3.10 -wow) Cem ent ito,5 jack mLe
<br />Grout Seal Depth 5 -49 fa 0 (94 gol
<br />0 Manufacturer Spec„:„1.0, solids Name 0 Secn onFc 0 Speen Snahmitted
<br />0 Rentz:mite (20% solids) .%
<br />Great Phicarnent Method 0 Pumped 0 Free Fall Oth 7 0 Retardant / Meelerater (no
<br />Installed Sy 0 Drilla lIlAisp Contrgietor 0 Other
<br />'Mita 0 Ctiehq DOI 0 Stove Pipe
<br />0 Contrite Pedestal Dimensions: Width _,,... , - . II ft tn
<br />I 0 Submersible ItYfirrbine 0 Otter HP -Pump Set ft Standing Water Level __ ft
<br />I HFREEY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT T ,
<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 I AM IN COMPLIANCE WITH ALL
<br />WORKERS COMPENSATION LAWS.-
<br />24 OkIR ADVANCE NOTIC MINI. i
<br />kt R D FOR INSPECTIONS . . .
<br />Stc,sto .4
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<br />Appli,natme Moto
<br />Grout Inset- _o*tR --,.....we° . . ca SPECIAL Well Permit ,
<br />Pump lespernen D ..e ' Doti .52•,-4/`=C'‘,/"..' ' ' + 0 WAIVER Recei*ed
<br />Constructed Well Deptl Ilt 1, S p'..•
<br />COMMENTS
<br />nic Retefliod Servke Request a Invoke a Well UM
<br />C WO
<br />1 t”'
<br />y
<br />-7, 1S-Ar adar.,o Lf r icrb:3ER2 iniftb21i(3
<br />ILI' 007-1404 4.0T) aS-0 1/.56 • 4/1..) Se...005.3 ea 3
<br />let Li. P5/MP rE104',7
<br />9 *
<br />01, t'2
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<br />A ICI NT
<br />Vot Arta Employee 104 - 3 Fo P?
<br />•
<br />•
<br />SAN lOruiN Corry ENTIRONME
<br />fitOci-02.421,1,
<br />1/7,V=IS
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