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WELL/PUMP PERMIT , <br /> 1 SAN JOAWIN COUMY ENVIROYMENTALHEAITN DEPARTMew =>b-tTplW/D 304E WEBER AVE 3"FL-SroCNTOn CA 95202 - (289)4"20 <br /> NON-REFUNDABLE PERMITp CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Has ADDEI. C r .'ehfinI. <br /> I owizer L <br /> CRc,SE STREET ADM Or•J —7.14 <br /> .14 <br /> OWNER NAME / L" y PIncai�/ <br /> OWNERADDRESS / CITY/SEATEMP ( } <br /> CONTRAc-EOR NH f)� PHONE <br /> CITY /���Z'I <br /> r� <br /> CONTRACITIR ADDRESS /� /STATefLIP � 1//�/ <br /> SUBCONTRACTOR 1[ Ir PHONE <br /> SUBCONTRACTORADDRESS CITYISTATEJ�ZI 4 A%/`� <br /> 935-7 <br /> LIRNse C-57 Cfil Ll D.09 Ogher NUMRRA jv EREIRATIDNDATE <br /> GROGRAPRKA6 INFORMATION: CanrdlYW 3( Y TpWNbip. Ranee_ Seetbn_ <br /> INIRNREDUSE emViirivem ❑ImgmioNARnmitued ❑DMusnal ❑Wamr QVHily Monitoring ❑Sell SamplmE/Chemcmtianm <br /> ❑Public Went System <br /> Iraiffenwo rmmO wr aur rmm Name Cb.Nae.m Phea6 14m,he, <br /> Tyre OE WORK XNM Well Cl Replaeament Well ❑Well Altemlian/ModiEcHim 13 Text Hole ❑Other <br /> O Mneiwnng Well(s)_ 0Soil Boring(s) wmbwof Eonw OGrolahnical wnem oraaap <br /> ❑WdlDcavuclim �Om-0f-Service Well ❑Out-Of-service Well Ra..[New Pum CIPumplieplactment OParnpRepir ❑CrnaaLeneWionR <br /> epaw <br /> WEu.CoN91RUCERIN <br /> Drilling McHed 'XMud RM O Air Rotary ❑Auger O Cable Tool ❑Pueh Polnl ❑(xber <br /> Proposed Well Depth J. y fl EKcavalion_�Lin diem., 13Open Bosom )QGeavel Pack/Onvel Siu indiaoeMr <br /> O Condumr Cuing in diameter / Coedamr tieing Dcxh R <br /> Well Can.E Diameter j—in Th,eknmlGaugdASTM Schd 4"'0 O Steel jfpae tic ❑Smnlw Stal ❑Odpr <br /> Grout Seal Tmplh AV) R ❑N®t Ccmme94/bbuY/3-10Ya1wmer/ '6 S..d Cemon .r x:F Mix/7pl water <br /> entonia(20%solids) OManu WweTSpee%sdids % Name ❑Specaon Fi <br /> mle ❑Speer SnDmitRd <br /> Great Placee. W.-I meed ❑Flee Fell OOtha_ ' ❑RminelE l/A.1menitne.) <br /> PBDERTAL lastalkd By ❑Dnller mp Contractor DOlhcr <br /> O ConeeM Federal DlmnriRu: WMtb It Length_2_—R hick In ❑Christy Bas OBlosRrge <br /> POMP )0u1mersible ❑Turbine OOrha HP PmnpSct_ZJV li R <br /> WELL DerTWGrlon OOp.Baton aGeavei Pack ❑Unused ❑Oiber <br /> Well Dianmmr in Thal Depth tt Depoh m Wamr fl O Casing w be Perfomled from_fl m_B <br /> Seting Marerul ❑Nest Cemml(9416 AuY/3 10guf xuh) O Sand Cement sva mix/7 gd wHer ❑[Romile Pellets <br /> 0B.VHuw(2O%.lids) ❑ManuBetuw Spec%.lids_% Nara OSpcnan Fik OSpeea Submitted e ` <br /> Placement Mefbod ❑Pumped ❑Fra Fall ❑Other N <br /> ❑Complew with Mnshrmm Cap__N balm.grade ❑Complete in Eeweig Surface Ped 0 <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN �C <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 11 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIM UM 20 HOUR ADVANCE NOTICER��.QU IRE/p.Fil INSPECTI01 <br /> ONS <br /> SIGN TrcLey !(?1r//-E!K{� DATE 02~ (^^N111 <br /> IY <br /> S <br /> � . <br /> 0 <br /> oD2 <br /> S J <br /> q <br /> DEPARTM T USgam LV <br /> Application ATaepmd By D.4d 'Z Arca Employe,IDB <br /> Oroul Irupalkn By Ti— ❑ SPECIAL Well Permit <br /> pump Inspomton By Dine ❑ WAIVER Received <br /> 2 (s� r <br /> Dcawc[ion In rim By - stem !/ Coutrueled Well Deplb /f3l] R <br /> COMMENTS 1'i; <br /> d D <br /> E SC Amount Raa1vW Dak Permit/ InvoicaN WeII IDN <br /> Codes Info Remitted B N <br /> 0 ZZ a (0 3D D R OLI p 23 q'i <br /> ra <br /> IIHD O-W.oOd AOP <br /> 5=002 s / MASTER WATE0.WELL PERMIT <br /> �e[r ffY'P• f[/jL�08 <br />