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y / WELL/PUMP PERMT � <br /> SAN JDAQOw COUrePY ENVIRONMENTAL e�R DOaRTMENr JOIE WEBER An JasFBRSTOCRT0N CA 95303•rwtf�yan.���/F,/�� <br /> NON-REPHNDABL��E��PERMIT CALL 209 9537697 FOR INSPECrms EXPIRES I YEAR PROMDATC��IY t <br /> JORADBREES Mkd4+].(4A! St o'1t-gf �KS✓�GM2R <br /> cReassnen r rvT L AAE <br /> \ APN //��ZrS/�i-1O((o c7—O�I.ARCELBm I`�� LAem USEACeucA orp <br /> OWNER RABBI er,y (5re, - OC C4 l:lTlr,A rcyf .LNC . /PRONE' <br /> OWNER ADDRES4 IKW S'0,'T�F` P! S `T c�jr /5✓. �.Q�SUU emmAT!/Z@_(,N.(5 W �A I c-1 NST <br /> CONCRAc R C d-VAC � I'man ZU4 63to610 <br /> COMRARORADORERS cU TI '( rNcy ,Jf,A(J 0�- Cm/SrArr2v��tC 't ' `( - <br /> sugcomuRlR PBONE (a 6 40( -S.&a 3 <br /> suRCONRAROR AnDREX9 P C) 2 Or x�a CA Je 3 <br /> ,,gyMpp � GTR'/SfAT[2B 'I VI S6 <br /> LIC6NAE ¢C-57 ❑G61 ❑099 ❑plate NUMBER EEPIRATIt1NDATe <br /> GESN.MPFIICAL INFOBMATWN: Coeodiules X Y Tmrwhi, Rune_ Secdm <br /> INTENDED USE ❑Wmeeti.Trivue ❑hrigatioroAgri edwral ❑woubid ❑Wdm Q ality Moadicx g Soil Sunpli.&ACh.,Buiawti. <br /> ❑Public Water system <br /> RNrtwm�Omo Owesov. YAm a amm <br /> TyrKOFWORR ❑New Wall ❑Rep6.tWd1 ❑Well Alteretiar/MadifScatim mlod. <br /> ❑Mmitorin,Well(s)_p ofwells KSoil Baing(a)!_ gab0na,, OGeatmhnicd adneep, <br /> ❑ON-0GServme Wdl ❑OutOfSem«Well Renewd ❑Crooe-Cormeclio t Repair <br /> 0NowPuuvaa 13 Pr,u RI..i 0 Purnp R,,ir <br /> WmctmmwumON pT <br /> Drilling MMod ❑Mud Rotery 13 Ail Rotary A.w ❑CebleTool pvuvh Point QOther C 1 <br /> Propoad Wdl Dq,N 9-) ft Excavation n dianMer ❑Open Bottom OGmvel Pack/Grsvd Size in diavvler <br /> (3 Conductor Casing in diameter / Cooductar,Caving Depth fl <br /> Well Casio, Diameter in ThickneadGaugc(ASTM Schad ❑Steel ❑Plastic Cl Stai 1.Steel (3 Oder <br /> Grout Sed Depth ft If Nmt Cementf9xlb bog15-10gu/wmer) ❑Sand Cement .rmkmix/lgdwdcr ` <br /> 13Bmtoni a(W%mIt&) 13Manufacneer Spm%oulida % Name ❑Speem File O SpecsSubmitted 1n/ <br /> Groot Placeasml Mdhd ❑Pumped X.Free Fall I$J.khm TCCvvS:eJ• ❑Retardant/Aceelerdor(tume) <br /> PEDESTAL Iutdld By ❑Drilloe ❑Pump Cootramt r ❑ OdN+ <br /> 13C.Bmx1CPdestd Dimmriov:WWth fl Length ftnick ❑Christy Box ❑Siwe Pipe <br /> WASP ❑Submersible ❑Turbine ❑Other IiP Set ft Standun, Wstm Level fl <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TAT TRE WORK WILL BE DONE DV ACCORDANCE WITB SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 4` <br /> ONMINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> STONED TITLE TITLE T ec%q n a e C-4 DATE ID 1 h O� Z— <br /> ^S <br /> IY 1lTl <br /> r <br /> MEND <br /> - - EIVED <br /> R Y <br /> 1 4 2005 <br /> - UIN COUNTY <br /> NMENTAL <br /> DEPARTMENT USE ONLY <br /> S% <br /> Application Accepted By Due d Q'J Aree Employee lDp <br /> Gout b spwion a, r Date 0 SPECIAL WCD PCTPDit <br /> Pump lmpectim By Dau 0 WA1VF.RReceived <br /> Co ostrMd Well Depth R <br /> COMMENTSA <br /> Y� L' <br /> PE SC Recervd Ch de# Amoenl PnmiU <br /> Cda Mt. H Cash emittd Date wimR este levoimp well tap <br /> r{37 isc, NG .3F9.E <br /> p�p50m-pW WELL PSMP PERWT <br /> Nl/Na5 <br />