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1M .. <br /> .11/24/2008 11:07 2094640138 ENVIRONMENTAL HEALTH PAGE 01/01 <br /> 4 11 <br /> r.. �, <br /> ;,. WELLIPUMP PERMIT <br /> iAN JP�QaIq CpaN7Y ENyIRpNMENThL HEALTH OEpARTMENT 900 BAST MAIN STREET-$TOcrrrOAt CA 95202•(249)468^3a29 <br /> 4O��EFUr1D7+BLE PERMIT CALL(LOS) 53-7687 FOR IFrltoc ONS EXPIRES 1 YEAR FROM 1)11TE 155UE0 m <br /> h S <br /> los Aoart�s9 - <br /> d <br /> os APN Ph BxE LAND 158 APPt0A"N D <br /> .ROSSSTREET <br /> PHONE `� <br /> ]MEA NAME Ty TA <br /> INNER AwRIMS '7 <br /> f� PN4NE G <br /> eel <br /> CONTRxcroR�I' Z Z <br /> I CrtY15th7ErZrP <br /> CONTRACTOR A.oPRESS <br /> I NONE <br /> SVscuRTRACTOR .r <br /> CltttlyTA7ErZIP <br /> 311BCONTRACTORAOOR9S3 I �� <br /> NUMBS E]rPIrtATtON DATE � �(,,f I � <br /> LICENSE C57 ❑C.9i J o-09 11 Other — � <br /> !� y Tawtlshlp� Range Seetl*n <br /> GRoonAPN1 AL INFORMATION: CaordlnatAs x Im lChanacterizetbn <br /> lNTENaEa UIA DomssilrlPrW0 ❑1nlgalloNA�prlcullural ❑IrtGustrlal ❑WatAr Quality MOni45rin0 I,I Sall Sarnp g <br /> J Public Water SY51*DT <br /> ifawmlIr4M4w . I� „ <br />'�•••+�- EoF —K NQwwen—,Wn'ReplwoomentWsll ❑•Vsfclr.vterafionlMadkRk�Hon,AMti •^"^*oorncrrwc ..rrr^ �^..a�. -:,_r-�f eL�-{.L. <br /> E ,kl(pnitorfrtpwLll(9]�,_#of wells ❑$*ilSDrtn9(3) �I GeoteChnicelAiti�T��l �`J1L��` <br /> ❑Ouf.of-Servowell ❑Out.Bf-Ser+ke Well Renewal 6 Cmae-Connection RBp r <br /> NCw Pum ❑Pum Re scerruynt ❑Pun+ R air G Rolse Well Cesln <br /> 7Dr111lngMfttIWd0ML1dftc4arYj <br /> 11 <br /> AirRetsry clAuger �j(CableTpd ❑Pn t Padnt n OthWell ❑epth 2 R EXG?va8an 25In diameter oOpen9ottom ziGR9tNd 0mvel Size_ in dlarnBter <br /> C CondOM177fAvAM9�in diar iuW r Conductor Cesfltg Depth9ing MRMCtet' nThlaklrq,[C,upeIASTM Schee o Weal )KP14MIc ❑StainlessS I r)Other <br /> Seal DBOIh j.(7�ft ❑Neat 6�ment(04 fe aaPS10 980 a`8rer) <br /> )(Sand Cement „SE[#mlx17 4 water <br /> 13 BerHnnte(20%wWs) ❑Other IM , <br /> GroLdplaceowtMethod iPumW n FleeF.0 1I❑011ier r]RetoMantfAcooleratorOAM) <br /> Pow- installed BY ❑O IW ❑Ptttn7 Contractor ❑ ofhef <br /> n Conorete Pedestal Dimenul*ns!width ft Length ft Thick in L Chrlaty Bax ❑Stove Pipe <br /> JE!VMA ❑Submerlu'bleO Tur%ne ❑Other II HPPump set:,, A... Standing Woter Levet fl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE W;TN SAN <br /> JDAquW COUNTY ORDINAN0E5, STATE LAWS,AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH TIME CAUFORMA`CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP SATIDN LAWS, II <br /> MINIMUM 4 HOUR ADVANCE NOTICE REQUI O FOR INSPECTIONS b <br /> SIr,NEe iM TrtLE DAT£ <br /> iF <br /> O <br /> � p0 <br /> IL <br /> I� DEPnR MENT USE ONLY <br /> Q/�(� <br /> ApplkklUtm ADoe Dat* Ar9-1 Employee IDP1 W/ 9 <br /> Groat Ins --,tion BV Da1s� ❑ SPECIAL Well Permit If <br /> I <br /> Pa0 WAFVER ReCAive�. <br /> rrePrnc ay fI ❑ate�� <br /> you BarSRn cdoa,3y �! Date ,...�.— ConslrutEed Well DeP11r ft <br /> COMMEW <br /> PE SC Rxeive0 ee 6 Amourd Imolcetl Wnllf /)g <br /> Codes info By Cosh II ReMM9d Dato SMww Ro uesl# 7 <br /> rJ1643-08 WELL"MP PER - �/•�� <br />