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HENNINGS BROTHERS Fax:209-545-1729 Apr 30 2012 10,10am P0011001 <br /> VMLLrrur+nr Vt=K vII I <br /> SAN JOAOVIN COUNTY ENARONNENTAI HEALTH DEPARTMENT 640 E-U7 MAIN STREET-ST00(ON CA 95207 -4209)M"420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76197 F0A i45FECT10NS EXPIRES 1 YEAR FROM DATE ISSUED <br /> X300c1 Rd,, G1TYlDa rCv ql Say <br /> doa APOREEc A lAL t �f 1, /'1 l $r <br /> GtOna fi.Rllr mV1�77 r,t karAPN 213 <br /> -02_]' l PARCEL SIZELAND Ute A>nL�CATION 4 <br /> OWNER NAME lW C, <br /> OMERADDRESS �9 �-C16 Q S,,'T'" C1TvHSrAT>JLv�T�erfY\.dfC.C8 4�is5) <br /> CONTRACTOR <br /> CONTRACTORADDREaa a Crrv15TATEJZJF <br /> sumoNTRAM(M PHONE I <br /> SUBCONTRACTOR AoQRfa6 CI1vrSTATfJjly <br /> LICENaE 57 C-61 D-09 Other NUKEER <br /> EJ;PIRATION DATE <br /> GEOGRAPHICAL INFORWATION: Coordirliior % Y TownSitip Range $eCIIOn_ <br /> INYCNOEO USE OOMesi-c/Pnvate tilfrigallontAQII.Cultufal L- Induslnal -,VVater puallly Monllonng _�Sail SemplingrcharaaercTBttm I <br /> PO014c Water Syerem <br /> lld:IN+tK,bvm 0-0- w5w y4 Fri On 0 erv; OM y,•naar <br /> TYPE OF W61tkl( ew Well Replacement. T vJsJI AllerailoVUodlhrzimn - Other fl <br /> i3rtla s <br /> .N.ondonng Wella s} OT v+Bll9 i..Sod Ba.Tng(s) � �' Groterhn.cal KOI llia'""w <br /> Cui.Ot•SerAc Weld i" Cul-Of-Ser m Well Reneiwel D CrDee'Ccnnecildn Repair <br /> Naw Pum ] Pum R Cement L Pum R4.d`r C Raise Will res—nI <br /> WELL CO NeT uCTIO"' 1 <br /> Dnlllnq hAethod ud Rotary Ar Ri)tary C ALger -.Cable Tctii t I'Wi,PO'nt - Ohher I <br /> i <br /> Prlopased W411 6ptn Q it Fzuveeon L <br /> A In dlameier C open Bo"Orr XGravel PEiWGrs,ei Size in dlealtler <br /> Conduao Ceanq Ir.dlamrrer Cor dueler Ce41ng Depth. fl <br /> Well Ceelnq D.ameter j3in TThInesw1,G&uge/ASTmSci--d � -Q Stool 1a91ic C Slainle435tS411 0fritr <br /> Gram Sa al p pineal CemFnl(Q4 1p D%Vi -'D Be+wereo Send Comeni aac+i T+ixr7 gas wa^er <br /> ertanlle 110%sOtF.er <br /> Grout Plac4ment ethod .PumpeFaN � 011161 .. RaTaccant r Attelerwor(narne) <br /> PE.DEBTAL instalied B -E'DAller <br /> By r*"P l:onlr4apr _ Cllner <br /> Concrete Padastal Dlm MI() s-W,atlt R Lgnglh R Tt+�ct in Chrlsry Box Sta,e Pipe <br /> Puny C SuhmeralGle- TilrDlne C Other HP Pump Sei R Stwnding Water�6ve1 ft <br /> I HEREBY CERTIFY TWAT I HAVE PREFARF0 THM APPLICATION AN;) THAT THE WORK WILL BE CONE IN ACCORD NCE WITH SAN <br /> 10AQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CER71FY THAT MY REQUIRED LICENSE 19 <br /> CURRENT AND ACTIVE MTN THE CALIFORNIA CONTRACTOU 6TATE Licu N9E BOARD AND THAT I AIH IN CO'MFLtANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> A111411VILIM 24 !OUR ADVAAICE NGT}�}CE RFOUIRED FOR ICNSPECTION$ �} <br /> SIGNED r-- 11(LA > d�' 1N?JCf�r•', <br /> DAT '�•3 Q y�Imo.. <br /> f E <br /> 00 <br /> I <br /> I <br /> RECEIVED <br /> pPR � <br /> SAN <br /> a 2412 <br /> SOAQUIN COUNTY <br /> I)EPABTMENT <br /> A TMENT U 3 E 4 L Y �I/l <br /> pppls:w-on Accept6d By Dale A O y Area Employee ICA X144 C <br /> Gros In.peclon By Dals /_ Z SPECIAL Well Permit <br /> Pump Inepecl an by Dale WAIVER Received <br /> So&Sol rtg Ina edlcn @ Date Cons u,: ell Depth <br /> COMMENTS LCX� <br /> r � <br /> P15C Rtctivtd ReG N Amount Ate PNr1Rit1 Invoice R 1hJe p1 IDP <br /> Coate 111100B Rsmlunl. Service Request 4 <br /> ENDrb# wE�_TUNR PERMIT <br /> OM400 <br />