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WELL/PUMP PERMIT <br />' SAN JDAat1M COUNTY EwARpmmNTAL N6ALTH DwAtrnwff I N8 EAST XA3T0M A*Ul-SROORCM CA 95205 - (209) 46&44= <br />NON-REanonwei.E Pour w CALL (2091953-7691 wR bawecwww �� 1 YEAR FROM DAA Ismer <br />ad �.r-y tx ca (� cf 53 <br />CA� STREET <br />a G 3 GG <br />�` PARC$sl� . k1 0 <br />Organg Wood <br />MW Rotary <br />n <br />Il 0) J 1 If I o I I / <br />� I �](* <br />lOvmER Nwf <br />k T ! i <br />In diarnager <br />OwN�u anoseFss <br />,fin <br />n � <br />6 <br />CONTRACTOR <br />c� l <br />Co rRAe-ou AovftE= <br />Well Casing <br />!SUBCONTRACTOR <br />ThldmesslCiatpWASTM Schad Steel Platin : sb*d 6s SOae! Qatar <br />wtaTy <br />A� <br />!— <br />SUBCarTRAt.'rote <br />uceisF <br />Aaotct <br />C-57 C-61 D-09 L) t <br />�v) <br />sadt mod% gal water <br />GEOGRAawcw <br />I,!W- J DAMN: Ceeednabs X Y <br />TaWnSAIP_ N Sacftn_ <br />INTENDED USE <br />y" Dornes=Pm—ate ItTlg3tbn/A7lcuX7ra! Ir4jsvw <br />Water QUtlRy UonSprlrtg Sol <br />Rea Fal Omar Retardant I /tOoovow 0t <br />drtW�Or systlam— <br />1PEDESTAL <br />tnadgad By Drilar <br />. Pump Contractor other <br />1 <br />TYPE OF Worst <br />New Wet! Wdacemsr+t Wag Wel AfteraboVMcdification <br />cow <br />MoiitOMg Wed(s) sat welts SOd Bc tw(s) <br />adeorh" .GoondaYCal edt�q. <br />tit-C)1SarviFe Out-OfSCr Aw W eA R&,evA 1 CMU -Gonne SOn Ropaf <br />D�ne,,._1___ __t .Ph Pn r Rae Wag Cybn <br />mu Corm txnaN <br />n rt <br />y <br />Organg Wood <br />MW Rotary <br />Ar Rotary Auger CaNs Tod Ptah Poet OGw <br />Proonsed WeN <br />Dench <br />ft Esavabon * ^ _ s* ^ -- ° +"-^ 'y ai As.'4r _ e_ <br />In diarnager <br />Corxtu= CamN <br />in damotor I CordWu Casng Depth R <br />Well Casing <br />Dmmeter _ in <br />ThldmesslCiatpWASTM Schad Steel Platin : sb*d 6s SOae! Qatar <br />Grout Seal <br />Depth <br />ft Nest Conant (tu ib bog'— gal —tws Scald <br />sadt mod% gal water <br />Berunrt (21796 safds) 00ter <br />' <br />1 Grout Pfteemertt <br />Medbod Pur4md <br />Rea Fal Omar Retardant I /tOoovow 0t <br />r b <br />1PEDESTAL <br />tnadgad By Drilar <br />. Pump Contractor other <br />1 <br />Pedestal Dbnwalons. wktm _ R Th10t eoz �eove Pipe <br />Puuc SuErnersibie Turbine Ohtr HP Pt— R WatarLevel ft <br />Q <br />HERESY CS;MI THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN <br />IOAQUIN COU AN <br />ORDINCES. STATE LAWS, AND RULES AND REGULATIONS 1 ALSO CGRTFY IAT MY REQ1J� LKS Is <br />` CURRENT AND WITH THE CALN:ORNIA CONTRACTORS STATE UCENSE BOARD AND THAT i AM N COAH"JANCE WITH ALL ^ <br />"O ERS ON LAWS. 1 <br />MINIM OU ADVANCE NOTICE REQUIRED E S?ECT)OI�MSy-(P'LEf/ASECALL (209)_ 7 w <br />SIGNED TIRE "�' '� i� (4 "I./ ' DATE <br />i <br />11 L <br />Ac7r��;tfE■EEE■■■EE■�n■■■��■■■■■■■■■■■■■■®■■uM . . <br />■■■■■■■■■■■■■■■■IJ ■�l■■�■A\■■■■■■■`■■■■■■■■■■u <br />IiiliWlii�Y■■■■■■■■■■■►■■I■■■■■■■ilM1�■■�!■1■■■■■■■■■■/■ • . � <br />■■■■■■■■■■■■■■■■►1■■tl■■■■■■■■■■■■■■■■■■■■MEMO • <br />■■■■■■■■■■■■■■■■■■EV■■■■■■■■■■■■■■■■■■■■MEMO <br />-DF,PARTMENT USE ONLY <br />ADW =On ACZe%eC By dl�_ Dato 3-;2 6 - Araa 3 C C� Ernpi, Ow AkxtA P i� <br />Grout Inspect= Sy Dm I I _ 3PEMAL WWI Permit <br />Rump insperaon By A = WAVANt PecetvaW <br />Sal Sorno Irtspemm By / Date papgs R <br />:.OMMENTS flA') A(t(1f iC(( 1fbtu <br />END , <br />P <br />W81 <br />4Bet2 AlA� F3bJtT <br />