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SAN JOAQUIN COUWY ENVIRONMENTAL HEALTH DEPA EtRELL/PUMP PERMIT <br /> 304 E WEBER AVE Sep FL-STQCXTON CA 95202-(209)4683420 <br /> NON-REFUNDAaLLEPERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 07-3 ATT fl (,�, ( /f <br /> f V /—._SL____ Cr1YrzIPJ <br /> • i CROSS STREPT 1S -] 0 —= i / <br /> 1 APN�G��I^ �j pARCLL 512E //. 9-AND USE AVH.mATION M > v <br /> OwN[a NAME Lt YJ <br /> N PHONE 6 <br /> OWNER ADDRi-tis j { S ` <br /> CRYISTATUyIP <br /> CONTAACTDR SQ`/{S• ° .r __......�. �y <br /> PHONE <br /> CONTRACrOa ADDRESS -/ {}lP]QµS Mf CITYISTATVLIP <br /> SUBCONTRACTOR_ <br /> PHONE$UBCONrMCma ADDRESS_ <br /> i CITYf$iATVLIP � 1 <br /> LICENSE C-57 ❑Cil ❑D-09 ❑Other NUMDE �'P <br /> EXPIRATION DAIt <br /> GEOGRAPHICAL INPORMATION: C,,,U,m K Y <br /> Township__ Range__ BNIIOR <br /> 'WENDED USE ' ❑Imgalion/Agnc.... ❑Ndusmal -- <br /> icW.uuSystem ❑Water Quably Monitoring U Soil Sampiing/Chalacterrn0o^ (� <br /> rr�,amm swr rsam .me .-.— <br /> --i'.anRe— tlTsme«TrRu <br /> TYPR OF WORX Well O Replacement well ❑WeII Altualion/M Wificnion ❑T¢{Hde <br /> rBlE1_,._ ❑Other❑MonimdB Wdis_, <br /> _ <br /> ❑Cemmhmical adh°dnp <br /> ❑Well Omour ion ODUI-0f-Service Well _-- ❑Uu40f-genire Well Renrwal <br /> 7R.W, <br /> ew Pum ❑Pum R Iarement ❑Pu R it ❑Crp33-CDnPCRIon R it <br /> W <br /> ELL <br /> ud ROM, 4, ❑Air Roury OAU er ❑Cable Tool ❑PHh Point ❑Otherh a ._ry Euavetiwmuc ❑OpenBOlt➢m ❑Gravel Peck/GNvel Sittin diameter <br /> nductorf�ng indiarne / Coneuctg Dek _eter_(�in Thick11cDVCRugPJA37M Ssw ❑Steel -`aak ❑SrainlesSteN h -faL-_ �go,— ❑Other1 0 ❑Nnl Canenl(94 fA APg/S-IOgafwmv) ❑SendCement wck m¢f]gal watu <br /> mm�ile(20%solids) ❑Manufumrcr Sim%Solid _°le Nameod ❑PumPW ❑Free Fail -- <br /> OS Specs on File ❑Specs Submitted <br /> OOkv ❑Retardant l Accelelator(no=)_ _ <br /> kited ❑Drilla .— <br /> mp Cm.Iuaor ❑Other � <br /> ❑CDueratePedu l Dimeosiow: Widb 11 LengPo R Thicki to ❑Chris Bax ❑ <br /> PUMP ❑SubmerSibc Stove Pipe <br /> ❑Turbine ❑Other 1{P Pump Set It Standing Werer Level B <br /> WELL DESTRUCTION ❑Open Douom ❑Grave)Pack ❑L'wased <br /> Well Diameter_in Taal t ❑Other <br /> Deo h R Dep[c ro wiser R ❑Casing to be PEIfOmled from_R to_B <br /> i <br /> Scaling Material ❑Nrn Cement(941h Dig/J-IOgd-f") 13 Send Cement_ <br /> ❑Brntonite(20°A solids) ❑Manufacrurer5pcc•Iselids__^, Name °rgkmit/]gal water ❑ecemm�iti Pdlus <br /> Placemaat Ausaw ❑Pumped ❑1.Fall ❑Specs on File ❑Spers S. onest i <br /> ❑Other <br /> ❑Complete with Muabroom Cep Rbelow grade ❑Compicm mExiating Surkcc Pad <br /> JUAQUIN COUNTY ORDINANCES <br /> I HEREBY CERTIFY RD HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> CURRENT AND ACTIVE , STATE LAWS,AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW& <br /> I �1,�MINIMUM 24 HOUR ADVq,NCE NOTICE RF-OUIRED FOR INSPECTIONS <br /> SIGNED_ (�//I Ilr/1 O M 2 <br /> 1' <br /> A h <br /> VI N <br /> H E <br /> I <br /> EPARTMENT USE',JDNLLV�--�'j— v� <br /> ApplGrunt,, Accept. _ /- Dare-''?JL/ Arm .rL/ <br /> Fn;ploya lDM �./1 <br /> crow les rio <'dR paY7 ex ❑ SPECIAL Well Permit "Kf <br /> PumPlnapxtion By Date ❑ WAIVER Received <br /> DeDmclbn Inapeedon BY Date Constructed Well DePM_ In <br /> I <br /> COMMENTS ' <br /> • m SC Reeelvad Ch Amount PermlN <br /> Cdea Ink B AS u RamlOad Da{e )" oiceN <br /> O Service Rest VWeB IDN <br /> OZ 22. 6D .Avo - lot dvPccy �� <br /> ENDUA1aM <br /> L}}gp l <br /> MASTER WATER WELLIERWT <br />