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WELLIPUMP PERMIT <br />SAN JoAoum Cowtry ENvutommEmTAL HrxTlt DEPAt TUW ISW EAST NA$TON AVNM-STOCKToN CA 96206 • (269).6&-3420 <br />NON-REFumoABUE PERwr CALL (209) 953-7197 FOR bairecum _ EXPOM i YEAR FRcm DATE IssueD <br />J66ADOMEW ►Vl G(n •t( <G (Zd t m l(Arlto CG ( G "15 , <br />2,4 <br />.� ,• A� Cao= S7 n � cPA,RML- U <br />APN=A. 1CA <br />T10N # <br />eyr e � OWNER N.. ✓�v 1 <br />OWER ADDREsb -(-CCr4 Ci <br />CONTRACTOR <br />uau <br />CCWRAeroR AD,,.= 0 <br />SUBCONTRACTOR N 119 ,Q .�RY1ST� <br />SUBCONTRACTOR AODRl.SS l ^ <br />oC 1 lY lY �V u <br />UCENSE C-57 C: l 609 otter, 1 Nwleet g�DeenOloN DATc <br />GeoGRAawcx Irrt%02Gr10N: eeerdnates X Y Tee,nfltlp_ Rarw. Seetlon_ <br />INTENDm USE V U0TE6=FM'We 1rrig&C0n/AfrX= rat molls al vvaw uumq monmxwg 30 owu <br />W� a <br />Tree OF Warm New Wag Replacement Wei Wel Omw <br />Mwrtomg Wee(s t of webSod BOntTg(s) e d EarYf� . G., .' lied eo/barLrgs <br />OIY-OfSeMCe Out -0f -Service WeA Renewal Rp&ir <br />New Pump P mp Replacement Pump Repair Wiq We& C9WK1 <br />MINIM Method Wad Rotary Air Rotary AuQa Caete Tool Pian Poirot Otlw <br />Prglmad WON Depot_ ft E=waw m owrneter 'open edmm Gravai PoultiGravd SLze n mamecer' <br />Cadu= CasM in t9irtww / Conductor Casing Depth R <br />YYe9 Casing Diameter _ m ThK t es&KMLgdASTM Silted Steel ' Pla&uc SwWm Sped Odd <br />Grout Sed Oeph ft Neat Cerra t (At 8 bsy3-10 gal mdoot) Seed ssdt mW 7 gsl water <br />BWdwite (2D% solids) Outer <br />Grout Ptaaynertt Madood Pumped Free Fag Other Retardantl Awww8 Or om"o <br />Pr Ai Installed By DrZw . PUMP Contractor Other <br />AmKorete Pedestal Dirrtarrsiorts: Width ft ft Thick in : ChrildY 5= � foove Pipe <br />PUMP V Subnomble Turbine 06te1 HP I Pimp $a--W_It *w4kg Wafer L&vd ft <br />1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WLL BE D= N ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LANK AND RULES AND REGULATIONS. I ALSO C2RW WAT MY REQUlRED LJCEEPM IS <br />CURRENT AND ACTIVE WITH THE CALFOR11" CONTRACTORS STATE LICENSE BOARD AND THAT 1 AN N COMPLIANCE WTTH ALL <br />WORKERS COMPENSATION LAWS. <br />M! MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR I SAPE/C'TInONSp-�P/L�EAS,EE CALL (209) 953-7697 <br />SIGNED -ei r " TIRE �T, 1 y J Ct I C4(I DATE <br />m <br />N <br />N <br /><n <br />�A <br />y_ -ENT <br />4QUty C <br />D fNMfq'��� <br />F'lR SEM <br />OF�P RTMENT UAE NLY <br />Application Accept&& BY4A—taDate I I L Ar" Employee Wle&&�C-v <br />Grout inspection BY _ Daae ''l SPECIAL Well Weal p <br />Pump inspemm BY + 1 9 Date _ ,.A _. WN11et Received <br />Sot, BonngBy pate <br />A Gomtrueea'dMW 1Depth R <br />OOMMENTS d AL �i t�r� L �hf /er L vIYI -r-e ; y <br />4UO 2 MIfaL AIA PE7bJtT <br />0 <br />m <br />C7 <br />_m <br />m <br />n <br />C <br />