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WELL/PUMP PERMIT �O(t7 6 S' -- <br /> 8ANJOAOumCOuNTYEimitonvil1TAlHEAl111DEPARiYENi t868EAatllAZiLY011AVIIIUE-SIOCKto?ICA95205-(209)1663420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe Amass 2 5 /m 1?0, .y` CITYlzIP <br /> CROS381REET01 iolo /.—PARCELSueL:4.!�•LAND Use APPIICAIIOIIN <br /> OmaltHAEIE _S*L�rlll {�nj{('P'( 1111x1PTN*4! �� � Ptroee�L/l���fE�` rJ �(1 <br /> ChImIRAmeas �)Q; HOWARli 5'U CIj SVITt CIrv1STATE/ZIP ,'O YI CA 8/0!; <br /> CONTRACTOR <br /> CONTRACTORAODRESS ZrV4.5�i��n�rli�/1,.r S0211r A CIIYISTATULP ' .�, ; <br /> SUBCOIITRACTORtnVlC�t',�•. PHO11E )" ) �� <br /> SUBCONTRACTOR ADDREas 1535 JN0U)1n11)L AVG, CIIVISTAYU71P.3/ 14 NO> .�11 r/)112- <br /> I <br /> Ucause C•57 11 C-61 ll 00 II Other tluueeR t z IVI EEXPIAAT10A DA19 <br /> 0E0000I44ALINFORUA110N: CoordlnateaX Y Township_ Rango^ Section_ <br /> (NIENDEO UEE I-DomeslctPrivaie IIIrdgat!onrAgdcultural rr vidusirlat n Weer Quote/Mon!tedng Ii8o!ISemp5ng/Ch3racteraaron <br /> L Publy ergma.m <br /> Md <br /> rtrtre m mr. <br /> TYPE OF WORK r NAW Well r ReplacementYlell r Well Allerefor~kalbn IYOlher MULUko :% <br /> E1I.'nnilormgWe7(s) Nolae'IS L•8o10.1ng(s) .ort qa XOeolechnfcal acray+gs <br /> r Out-of-SerJcewall F Out-OESeMceWell Renmal U Cioss•Connecl'anRepair <br /> r New pump 0 Pu Replacemem r Pump Repair r RalleWell CesIn <br /> Will ConSTRUCTIOPI <br /> Or1111nD Malhod F.fAud Rotary r Air Rotary 5(Auger I)Cable Tool II Push Point II Other <br /> Proposed Well Depth_(( Excavalbn In diameter nOpen -e1 ac et <br /> (-Conductor Casksg In diameter / Conduct.Cesklg Depth { R Y t D <br /> Well Casing Dlantater`In ThFAiless/Oauge/A5TA1 Schsd n Steel r PI t!c n 1 r 11 r Other <br /> Orout Beat Depth n V,NealCement(9415bay5•f0gallvafed 1:8a sen Iwat <br /> L Ocntonlo(20%sorids) 0 Other ���"t <br /> Grout Placement Method I I Pumped a Free Fell Other l l Retardant i u <br /> PEQE{TAL Installed By 0061!er 0PumpContraclor n 09"rDoing oaV pljE,tt�l.l <br /> I Concrete Pedestal 1 Oimenslons:Wdth R <br /> Length ft }J <br /> Q.IZ1 r Submersb'er:Turb!na n Other HP Pum Se vision <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TIIAT THE WI <br /> WOR LL -6 OE NB IN ACCO IC I SAI vision <br /> ! <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,MIO RULE$AMID REOULATION8. I ALSO CERTIFY TIIAT?AY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE VATII TIIE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WI7II ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> 61-to$r,•uce McCall Time president DATE 19-13-9013 <br /> R CF QED <br /> DEQ6 2013 <br /> ESR 0UfN CaU <br /> _ E4LTH Ep�R��� <br /> D ARTMENT USE ONLY �-`�n� <br /> AppEcat'onActep d y -1 �1 Area <br /> ^-l` Employee ID#—aS4i/r�.V6"S <br /> Grout Inspect' Data U ECIAL Well POfltlll 1 <br /> Pump inspecconBy Date ❑ WAIVERRBCelved <br /> So1 Boring InspecCtn By Date Condructed Wall Depth ft <br /> COMMENT8_ n i <br /> P8 8C Raeelvad CheekU Amount Date parng Invoice N Well ION <br /> Codes Info 0 Cash Remitted 8 rvicsRequest# <br /> / <br /> E ND IHd 1'/EIIR�U?PER\5T <br /> l'P)IZ <br />