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11 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTAUM 304EWEBPAAW21"FL-STOUKTONCAME2 p0%46"De <br /> i <br /> NON-REFUNDABLE PERMIT CALL I09 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROe�M'DA(T�E 19SUED <br /> t JOBAYDR® _i8J00 S He{7derson Rd CTTY21P Tra <br /> CROSS STREET Iron � ' O <br /> /4 � APN LAT7' I�O � �]4 PARERBDi 25� ' AG <br /> OWKLLNAME. �]r l^�mar}le/y.Cumm��,�D" 'r�FTf the - PPIIe/My,EE <br /> OWNER AODRM 110 1nUill Blrtl r./ C.',TA'am' 1fYs* CA TV391 <br /> COrTTRk=R Z/ St-ss tn.//A2 !c4A-11PHONE <br /> .I O <br /> CONro <br /> raAcawpOarss <br /> IZIS ;'g* 6-C,25oc //ti CITY/SYATE2TeA a. <br /> r <br /> sagcoxraArnpR ntonE <br /> SUBOUNTRACfORAOUREJO CDWSTATEZP r <br /> LIMME XC-57 OC4I 0D-0 OOther Nam[0. 'EENIMTIONDATL J <br /> GE:OCRAPRTCALINFORMATION: Cmrdmol— % Y TenmM A <br /> IN iumm UsE O DmmtirJPdrate O 1 m_ Rmge_ Smtbe <br /> rdytioNAgrimlmN Olodupdd OWMer Qu.liry Mmilaing <br /> C)Soil Sanlplivractvimdon <br /> h <br /> OPuWammornen a r gKTleO <br /> UAffOrtwmmt tpO.m r�. v„ l <br /> Tyra OF WORK 0NEW Wal- 0Replacevwm Wen O Well AItemdedModlEcmion 13 Test Hde OOther <br /> OMmitodng WellU)_ 11eilaerMh OSoil SmI*H_ iii eaaaem OGmlmhnlN_ NmdwefANp <br /> OWell Dmuuction ❑OuWFSrnke Well ODYtaRServke WdlRmewd <br /> 0 New Pump O Pu R lactam' O PUTE Ramair O CrusCon ectian lbcait <br /> WELLComma pos <br /> Drlllmg MethodC!Md Rmvy OAir Rally OANW 13Cable Tool aNA Pwnt OOlhc p <br /> Proposed Wen Depot a E..tion In diameter 130ye.Batom 0Cnwl Pk/Grarel Sim_in diameter <br /> OCondmtor Cuing iodiamFHu / CmdwWrCuing Depth D <br /> Well CNtleg Diameter_m ThkkmadOaugdASTM Schell , 0 S m1 O PWdc O Smkkm Stoll 0 ONer <br /> Great Seat Depth_11 O Hat C..,(34 lit Aug 13-10,Wa ,) 0SAW Cement aN3 a Ir 17 gal eater <br /> O Bmedw(20% lid,) 13M..ukaaer Spa%wlids_% Name OSpeeson File OSpm SubmiLEd <br /> Groat Placemem Methed O Pumped O Fra FEU 13 Wer 0 Remdul/Accelerator(mame) <br /> PMWAL luraned BY 0Ddller 0Pump CanNBewr OOther <br /> O Cmarme PedroM Di ..does: Width R Lgot B Thick.in OChddy Bea OSmwpl <br /> PU OSubmvvbk O TaNIm O Dlher <br /> HP_ Pump Ser_g SlmIlmg WA H,Uwl R <br /> _ WILL DKERUrnaN 13 Open Bottom ❑Gnvtl Pack QUneLud OGNer <br /> Wdl Diamaa_iv Tad Depth R Depthb WRkr n 0 Caabg w iNRrfmded Born flu B <br /> Sealift Mzk l ❑Nat Cement(94 lA hati p ywl von) 0 Smd Cemem_aae*mir/7 gal voter .O Banwite Pellets T_ <br /> OSmmnim(2O%wlldr) OMawfi HNw %wlidE % Name <br /> Spec OSpeu on File 09pm Submipd <br /> Plmemvt Method O Pumped O Ftm ttin OOlher <br /> O Complete with MuWmanCw Rbdaw pale ❑Comph:s m Eziomg Surfwe Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 1 JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE M <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> M�IN/IMU�M/214 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> Stento_ L-...� W N- TIRE <br /> I <br /> It <br /> J� <br /> Y <br /> _.. .� <br /> Application AceepledBy.. Arm mployeslDp /3Xo <br /> 0.1 lupaticn By Date ❑ SPECIAL Well Permit <br /> Pamp lm;wtim By C' Demp ' ❑ WAIVERReeelved <br /> Dutmclien lnaparm BY Date lb d['1/ ConnrudWWdl Depth B <br /> COMMENfT ' <br /> PE SC Am <br /> Coda lett. R.=1 use B red MIe PmaW I.rdpp Well IDN <br /> h Sarvlea B <br /> �5 - 4fd3o b �i o2 1 <br /> p <br /> END -006 <br /> 5naRD DA-02MATTER WATEK WPERMIT <br /> END <br /> j <br /> a <br />