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WELL/PUMP PERMIT <br /> 'SAN JOABUIN COUNTY ENVIN)NMENTAL HEALTH DEPARTMENT 304 E WEBER AVE Y`FL-ST N7r(104 CA 9902-(109)14&3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADoaEIs 5ff5$4 S MCIA jja24 ]Q. arv/EIP Fro mAN Ccwnno °(SZ31 F(b21 <br /> e <br /> CROSSSTREET vJ ACAkhA0J51Lj APN 16[9-Z00-06 PARCELSI2Ebl°' j,ANO USE APKICATION 0 S <br /> OWNER NAME (may FreewvttA PRONE <br /> ZMAINREEE Y. 144L1 ClrvlsTATVPJPFIQIft'%NtiUw1°ICA RSE3i <br /> C]IMTIAC[OR� QGT�9y1 CTCC*#LN Chi PHONE(G 1 b� �'T 1_Oy 34 <br /> yl - � <br /> CO c:rGRAOURESE 11 L10 ?Ar CG n RI V A- CITyisty naJr Wet{'$aT,gANYA1rvLFB�CA 4S(e4i <br /> SUKONT Milt (:U%NtV CT-+:C2, lSTTA�"f0✓1 Fmon (C1LV))iz4'eZ'Ip <br /> SUKOMRACTO'a ADOREAN 3644 Qac wTrio 'R�. CITYMATE21r &Ar J.4Ne CordayrX 6NOE;14 <br /> LICENSE EIC-57 OC-61 COW 13 Other NUMBER �- ExPlax7jiuvDal 170 Oat <br /> GBDGRAPIIIC.SLINFORMATpN: <br /> Camel X Y TawmhlP— Rae{e__ Stella"_ <br /> INrENDEDUM ❑DomesOGRivate ❑IrrigmimfAgriculthal 0Industrial OWamr Quality Mmilon.g Soil Sampling/Chmctcriatim <br /> Q Public Witter S mm <br /> Reirtaml rmm ..u. .tar nam �m —Ta1. <br /> TYPEOFWO" ❑New Well O RcpLuemcol Well O Well AhemtuadModlOcotim OTat Hole OOdHr <br /> O Monitoring Wdl(s) pofWT14 56ABOung(s) s1 rvrSwsr.D OGemchnical <br /> ❑Well Destruction ❑Out-Oaservice Wel 13at-0f-Smite Well Renewal <br /> ❑New Pm2 O Pump Replacement ❑Pump Repair 000xai-CotmecticaRepair <br /> WILL CONSTRUCTION � <br /> Drlllina Method O Mud Rotary [3 Air Rotary HAuger O Cable Tml D Rub Point 0Other <br /> Proposed Well Depth IU"ZO R Ficrvetir:n6" n dumcter ❑Open Botmm ❑Gravel Pock/Gsavd Sia in diameter <br /> ❑CoeducmrCuin{ indiaraee / ConducuNC.cmg Depth __R <br /> Well Casing Dismal Muckneeel(h ugUASTM Schad ❑Steal EI Pialic ❑stowlas Sorel 13 Other 0h <br /> Grout Seal Depth_ R ONas Cemall.M 16 An15-10ga(wonr) 0Sead Cement _ruck ole 17 CA Ware W <br /> 0Bmrtmite(20%Mlids) ❑Manufecmar Spc%.hds__% Name OSWsm File ❑Spectra Submitted <br /> Grout Pit,emeot Method O Pumped O Fra Fall O Other ❑Aeardam I Aaelrnmr(rune) h <br /> PEDESTAL altelled By ❑Driller aPUmp Connacmr ❑Other <br /> O Coaerde Pedeual Dimensions: Wadth ft Lmgth R Thick m O Cbrb"Box CISIowPipo <br /> PUMP ❑Submrnibk O Turbine OOthe__ HP__ Pump set_ft Sanding Wsmr Lcvd ft C <br /> WELL DESTRUCTION 0op.BRn4m OOravel Pack ❑Unasd 13 Other <br /> Well DfavHmr_in TN&i Depth____fl Dep"to Wsar 9 OCaringtobe Perforatedfrom_ftm_ft <br /> Sllg As�`rr`aal��s q Nwl Ccmat(9418 bag 1J-10 gal wmery ❑Sand Cemem_rock Mh 17 gel eater O Bectooi a Pellets Z+ <br /> prw7uerilbl(ia(20va solidr) OManufacmrer Spec%solids_ % Narrc OSpae on Fib ❑Specs Submined <br /> PINumMIC�bed ❑Pumped O Free Fell O Other__ __ <br /> ❑Compkre with Mmhranm Cap Rbelow grade ❑Cam km la Exh4ng Surface Ped a <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPWCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN riS <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOI JCE EQUIRED FOR INSPECTIONS gj <br /> srONW <br /> TITLE, �gar DATE II p <br /> M <br /> PNS <br /> 9 <br /> rvr 1 <br /> FP <br /> DCPARTMENT US ONL rJ q r <br /> Application Accepted By leak S d Area ER�olaya <br /> Grout Impaction By/- Date ❑ SPECIAL Well Pemit <br /> Pump Inspection By Dam ❑ WAIVERReceived <br /> Desuuatmo Impaction By Dara 9A Constructed Wall Depen R <br /> COMMBN W i -4— ( £ fiLl.., uJ</J UG.r.v S '.Cr 6e <br /> W 1 T A{ N N T t S.l(♦ r (T� G4i f� Sf <br /> Sat f 1 <br /> vs. SC,. Received Amount as PerMU Invoice{ Well IDR <br /> Codei efo shRemitted Service Requee, <br /> 4372_ )sec f-0 Iry I J1 0$ <br /> S 1 <br /> FImOMtaa MATTER WATER W ELL PERMIt <br /> 1}?UIOm <br />