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P <br />SAN.JOAOWN COnNry ENM WELUPUMP PERMIT <br />NO.•- M^REFUNDABLE— PER.,, A� ALTHDE►ANTIMEM <br />CALL 209 '868 EA-HALELT0111 NOe STOCKTONCA96205 <br />IJwtAnaREas 2323 Port �— 37897 FORINSvec o (209)468-3420 <br />i E;D CJ G _ EXPIRES !YEAR FRDAf DATE ISSUED <br />jC8os0 STREET P.`; z t ;'!. 1 Q I"�"P!V ��(!/ n"-��-- n L`... r• t - <br />t `d r3 APN1 G ni <br />IDwNER NAME C Z/ PARCEL SpE 7/�1 UNO (jsE APPLICATION O_ <br />7! C. �-' C <br /><�NERAootttss_7— )l�`�m�` PIwnE.JC7p-Y�j"r — <br />[CONTRACTOR�•• T C"VISTATEIZlp <br />f (3„K AsSOC.i.ates�-4 d e <br />(CONTRACTOR AooResa 314f) i;o ld L arm, PHONE 916.8s3 92 q 3 .. <br />1susco IrRACTOR I%T i rlf :ITC) CRY/STATtJ� <br />'-�r.•�?�_,�y�-BdI1Ct1A C'OTlinc <br />--�J56�7n <br />(SueCON"RAM-AtRRtsaa P-- O g—_ _ ox 6093 PRONE 530.589.2019 <br />' LrCENEE X C-57 •, I C -6T t CITYrSTATral2yP (, 5 l r:, <br />DOtlEBTTC YYlLL <br />(( SAMPLING' Pr iGvaeteneral N!C_ NuM10®t 1 (i i � S <br />EfiPwn0N D,, <br />r,!-n!NofB8derj9 (4381)I J <br />Dlbram«ytI VW0Parte (4392 Arsenic (4383) <br />Agrrtlpurst _ tndus4iN • Water O -'- �-"-- <br />Putlne Water Sy,teT <br />nattw rt tm ownm• "y Moo tonn0--.— <br />n:MmyCharaCternAlton <br />TYPE Oa WORT --__— Wahw ST11sm Nwrq — --� <br />Now Wen • r RaWacamanf YVe ~-------_�,_ torero Nrne a Ph-. N„nrp•, <br />Monitoring Wel[(s t Wen Aneraffanft,, cation r <br />Out-Ot-Service 1 l 4 of wets Satl BorinB(s) _ a dnmrRp <br />OuI-%SefVk8 Wall Renewal <br />Re__WacernanI: ±iMvne. CrossConnectionRrdpair 1 eelm y. <br />M"In9 Method <br />MIW RoWIy Alr Rotary XP <br />'reposed Well Depgr�^n Aa9ar CMO Cxcavdnrnl foot Push }amt Other �- <br />Conductor Calan" E , ,n damarer <br />Well Casing Diarralter at T , M` hot*IGa dtxTu,tnr Carltludef C Open Botlam , Gravel Pa.klC.%,, Site <br />Grout Seal O OIASTM Sched a" Depth in diameter <br />"'�-- -n XNeatCcmtystU 5,r Steel I.IPtaMic <br />omStainfesSSteel 1:Olher <br />rout Piaee Bente (20% -ON., rAhar W 89w `mforl I Send Cement` <br />�. P�uffillede Fan QS'. Ofher ` r <br />------------ <br />---- ; - sacX mrxg gat water <br />------ <br />Mono` taY Driter prnt q�anTI ACCearalOr (name) <br />' PodeaW _ TP Contractor pq- <br />Lerlgpl <br />>sbmurslhb Thine `—_"�.21"11 ---... to chnary go� x <br />1 HEREBY CERTIFY "— Other ,•_�_'w --�_---_._900va P,". <br />JOAQUIN COUNTY THAT I HAVE PREPARED THIS APP --"-' P Set"—_•__ R <br />CURRENT ANDA CE's. ATE [.AWS. LIGATION AND THAT THE WORtt --ILL 13E DONE -Water R <br />TH ALIFORN IA CONTRACTS AND REGtfl,ATiON3. 1 ALSO CERT[ AT MY RCOROANCE vMN SAN <br />WORKERS NICOUPE N NLA TORS STATE LICENSE BOARD ANO THAT IAM W COME PUARNCE WITH IS <br />MINIM OU E NOTICE REQUIRED QUIRED F0RjNSPECTI0N3 _ m eAc_ -- - <br />APPIICallon Accepted By D A M peclbn By ENT U O L <br />Grout lns ate <br />1. <br />Pump Inspegton By _ - DBS --------.`. <br />Soif Boring Spechon By Date <br />COMMENTS T Date <br />r.H 146 oe,na <br />—1 -0 � <br />Area Employee IDo i�� <br />r SPECIAL Wel) P@Tmtt <br />4WAIVER RGCOived <br />O Canstn+oted Well Depth <br />It <br />WELL IPUW FEPNIT <br />R�"�NrftFcF0 <br />18N <br />r4,01? > >�� <br />�oFMFCfoU0A? , <br />1), <br />