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WELUPUMP PERMIT <br />SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPAMMMET 1868 EAST HAZELTON AVENUE -STOM M CA EM AM (TO9) 491-3429 <br />NOH-REFt1ND4LE PFR r wwws' ov_ ohd EXPIRES 1 YEAR FRoN DATE ISSUED <br />JDR AnoR6s CITY/LP ES / ,$' <br />�'1 D <br />CROSS$TritET APN � Vl�L� -' PARCBSKM LAND USE APPlJCATIDN� o <br />/' D — 2-%D JI -6i <br />OwIER NArff j (i f' � PHONE <br />OWNER ADOR6'44 C nVSTATE0r <br />CONTRACTOR ADORE s <br />LL)) CONTRACTOR SVBCONTRACTORICOM <br />u7eii _ <br />\11�iL <br />LilcemsE ❑ G57 <br />!!7t PARTY; <br />TANT ADDRESS _ <br />A-61 C D-09 <br />:1 OWNER <br />CMMTAYdIr <br />CITYISTATEIZP <br />nOttley NUMBERW574-i ElRATION <br />D COMIRACTOR ❑ SLMCONTR^Cn0RJC:0f=LTANT <br />R7NESTIC WELL ' U Genial NfineraffCAldam Bacteria (4391) U Dib <br />IorrlochlDTDprDpBne (4392) U Arsenic (4393) <br />frElaim U 11 Domeskipriv"- U h*fiOWAgrind"ural C In kaftial ❑ Water Q afity MOnibring D Sod Sa cel on <br />n Public Water Systen <br />it 06 r Torn Ower Water system Narrra .._ caMaa Nan. a Ptvs N,.rbQ <br />Ym OFF WORK I I New Well t Wei i Wei AterafirrLmkrrr.rar nx..,. <br />I I MOnrTorirrg Wel1(SL-_ B of weir I Sal BO"(s) f of bo1oay --1 Geole"3a>kaI <br />I cul-OFServi� Well I I Out-OtSefvice Well Renewal ! I Cr -r naHj— ae� <br />R of bongs <br />! ! New I I Pate i I Pump Repair s Rase Wei <br />Wym CONSTRUCTION <br />Drilling Method I I khA Rotary I Air P�bry I Auger I I Cable TOW I I Push Point I I Other <br />Proposed Wall Depth_ft Excoriation in diam T 7 Open Bott rn D Gravel Pacir/Graw4 Stte in dometr r <br />❑ Conthictor Ca=9 In dkunetar / Conductor Ca=V Depth ft <br />Well Caing Diam#m in TNCIMMdGa,gWASTM Scbed -1 Steel ❑ Plastic ❑ StaNess Steel C 0111a <br />Grout Seat Depth _ft n Heat Cerner" (94 It, ba -WI -10 gel wa" n Sand Cement <br />I I Bentonite (2o% so5ds) I Other sack �� gal water <br />Grout Pfamnle t Udhod _] pwnped L, Free 54 3 Ottrer L' Petwdont I Accelerator (Tom) <br />P83E5'TAL hntzfed By Q Dn%6( C,, Ot}— <br />ISO <br />'tlill I DlrtlerIDOn>ti' ft Length ft Th7dc n I I ChrQty BOt SUDve Pipe <br />SubmegsibleE Tlabne o Other HP _- �_ Pump Set ft StandGg Water Leve" <br />CF117r @ ] <br />I FTER�Y F T Alr r <br />JOAQUIN COUNTY ^^` wIu I HAI I Ht VVURK VELL ERE DOW 1N ACCOlwANCE WITH SAN <br />CURRENT AND ACTIVE y ICES. STATE WENS. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUITED LICENSE IS <br />THE CALIFORNIA CONTRACTORS RTATP I w FMee onAn A.... __ _- -- <br />/ DEPARTMENT USE ONLY [I <br />ADDication Accepted By ` �` Oale� Area 7 Employee l!)/7 <br />Grout Inspection By pate ❑ SPECIAL Well Permit <br />('%—P Inspection By � -D WAIVER Received <br />Soil Boring Immectlon By Date COnstrvdod Well Depth R <br />COMMENTS <br />w*1j-Muw PEF"T <br />VE <br />/ T <br />D <br />2021 <br />NTq NTy <br />7M <br />-IV <br />01 <br />w*1j-Muw PEF"T <br />VE <br />/ T <br />D <br />2021 <br />NTq NTy <br />7M <br />-IV <br />