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,l EL n,UNEP PERMIT ,7 'rit7 <br /> SANJOAQUINCOUr VENVIRONMENTAL HEALTNL ':RThIEM 104E WEDI:l, £J PL-Sl'OCKUN CA 9S2U2 - &]420 <br /> NON-REBUND BL/E PERMIT �1 :ALL 209 PIR3-7697 FOR INSPECTIONS /(PIRES 1 YEAR FROM DATE 11 SUED(9 <br /> JOBAD0.113 S, Cl'ylZIP <br /> Y <br /> CPOSS SI'REEr /I J� APN p,y�_ PApCE '2 IY "' F <br /> OWNER:NAME R //JJ "Klf� lr PIION f/ <br /> OWNER ADDRESS - -'T� ,dgiSz CITV/STsTF21P <br /> CONERALTOR <br /> CONEACrOR ADDRESS rV ) rLL� JI CITY/SrATFJ21P <br /> $Ullco,TtALTOR /�i � <br /> SU6C0N7RwM0RADORF55 � V T CITY'SIAAT�rOZ.1P'-YS/mo <br /> LICENSE -57 0C-61 6D-09 0Olher NUMIW.� `Y 'del EXPIRATION DATE_ d(j <br /> GEOGRAPIIICU.INIORMATION: Coerdlnetez X Y - TnlvpShipRungc Seelig. <br /> INTErvDEO USE ❑polnealiclprivao ❑IraigalmolAgricuhuml ❑Induxlrinl alar Quality Monitoring Cl Smil Samplia"Ch..med.d.. <br /> ❑P blic Wu c Sys <br /> :Dl <br /> Ownm. mar ymm +me Donn un.m un. ton <br /> TWEOFWORK y,.wWell ❑Replacemem Well ❑Well AirciniimilMailification ❑Test Hole ❑Other <br /> mel orwall, m,mber arwnnp ❑Geolechnicvl nuiwlrer6wiup <br /> nearing Well(a7 ❑So I Bo m g(s) _ <br /> ❑Well DsaPanun ❑Ont-01'-Stoke Well 0 O OEService Well Rcncwvl <br /> ❑Nnw Pum ❑Pum R[ laccnem ❑ramp Rc air OCross,Cannodion Repair <br /> WELLCONSTRUG"TOR �.,a <br /> Drilling Method ❑Mud Bell, ❑AURo4ry Pana r ❑Cable Ttol C2 PDA Point UDIte, <br /> Proposed Well Depth,--I B Excavation_ in diamaa ❑bpm Be".. 'Gravel Pack/Covet Sim in tliurcler <br /> ❑Coin Casing in diameter / Conductor Casing Depth R <br /> Wall Car., Diameter�in ThleknealGaugeIASTMSchcd Xnd/L7 USleel antic ❑Sminlese Steel Colonel <br /> — <br /> Grant Seal Ihplb_��11 )R2Neal Cemen104 A 1.,/3-I0enl:wrla,) ❑Sand Cement variate/7ga1wuer <br /> 08emmlire(201,asolids) ❑Monulvmumr Spee%solids_% Name ❑Sp[caoal'ilo ❑Spec Sobmined <br /> Grout Plveemenl Method ❑Pumped ree Fall ❑Other ❑Renrdem/Ae[elemtc(mame) <br /> PEDESTAL Installed BY 'X)illa ❑Pump Colttla[IOr UONes <br /> )SUCamras Pedestal ❑ nsions: Width �Z R Length ?-R Thick in U Christy Boa pnroye Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP_ Pump Sm IC Standing Wmcr,Level R <br /> \VELI.pt:mmo7❑n ❑Open Bello. ❑Omvel Pnek ❑Unmaed ❑Other <br /> Well Diamea in Teel Depth R De,,h IO Waer n U Casinglo Be Pert.eal t,am II in ft <br /> Sealing Material ❑Neat Cement(94 IL bag/5-l0 gal uaarr) ❑Sand Cement saVimk 17 gal wale, ❑Bauonie.•Pellets <br /> O Bemunile(20%solids) ❑Menufammer Spec%solids_% Name ❑Speesan Fle ❑Spm,Submiltul <br /> Placement Method ❑Pumpell ❑Ra Fall U Ofaer <br /> U Complete with Mushmom Cap A below glade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAI'MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINI M.24 HOUR ADVANCE NOTICE REQI1(1`12/ED,PpoOR,NfSPEC/TIONS <br /> SIGNED TITLE 1 Jfl — (.`y011/ DATE <br /> _ IRTNIE IHUSP/�Nl Y - <br /> Apphc ,o A`[eped By /`� Dote,r�L {l. �.tl_ A¢a� Cmyloyea Ml <br /> c ri apeotmn By p.le_w� ❑ SPECIAL Permit <br /> Pump inspection B Dale ❑ WAIVER Recelved , <br /> De¢ouctioa Inspection B, <br /> Dale CbnMrueted%Yell De h__ R <br /> COMMENTS .gL <br /> PE Be Amo Cl...k# Received Dme Pannill Involeeq Wall i Dp <br /> Code, Into Remitted B Service Beginslp <br /> SIR)43-02:0% MASTER WATEll\YELL PERMIT t it <br />