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7r, <br /> ' WELL/PUMP PERMITA}' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D[TAR[MCBT •~ , <br /> 30/E.% EXPIRE 6I YEAR <br /> N CA 95101 TE IS 9kt-JJD) <br /> NON-REFUNDABLE PERMIT CALL(209)9i1-7697 Fa,!p INsPEcflms EXPIRES 1 YeAa PROM DATE ISSUED <br /> JO[ADDRM rn <br /> CT'21P —T72A[Y�j5+32I M5 <br /> t.AOSS STREET ), <br /> I, PN IlJ')-/]n _PARCCL SAM LSJ.//ACIAnD USE Amu:ATION R p <br /> OWNER NAME 'TS,rrrn at. �r,.-_-..,...u�,�3 _../Lyf f &be pF <br /> PHONE 209-836-536---��� <br /> j OWnCR ADOR[Ln 3/2eT Mu! [ VA SLITS A. <br /> CRYISEATFI(JP <br /> CONlNU i R YBy..I�'d_e3l 7Z <br /> 4 C T <br /> 11�C <br /> PHONE b <br /> gy <br /> i. CONTRACTOR ADDRESS l Y4F'tZAA)K WEST G <br /> LZG ,SL.�-_r CTTVSTATEMP ST>x✓ay.4 rA 152404, <br /> SDK'DNTRACTOR �•[, <br /> SUBCDNTRACTOW ADDAPNONC =A�=Q7/l 1 <br /> cu 2:Gt WI Ae / <br /> - y CmSTAT p :DDD TdAJJ e—'4 9S&05 <br /> LI.. C-57 0Cdl 1313-09 ❑OIheT NUMBER I 2 <br /> E%PIMTfON DATL OI <br /> 4tOOBAHIICALIMPoRNMTIon: C'aaTdlneLt X Y Townablp 2 S IBuaiBw.,e <br /> m IN.,13DonRNRjdPnwh O lmipmnAgricWlurN � <br /> Setbn <br /> 13 P61ic W@mS= eIndustrialMcQualityMwimnng 13 Soil SamPlnpChanANpdp <br /> _ <br /> TYPE OF Wou 9LIrN Well 13 Rrylca:mn,t Won O WeUAbendoeMadiQutlw 13 Te&Hole 13 ON <br /> �Ntnnilaring WNl(q_LgiofwelHI�1139oB Bonn6(E) Eefb w 0G.Wht aerawinp <br /> O WNI Omc <br /> atdon I!1 Cl ovt-0f-Smlm Wcll O W <br /> W tq- <br /> 13 New Pu 13 R ! Srrvicn dl Renewal <br /> 13 0. 'r 13CmntAnneNimR it <br /> wcw CONSTRumon <br /> DNlling MHhad ❑Mud Robry O AIT Rotary XAupr 13 Cable T.[ O Push Point 0Otha, <br /> Propued Well Depth / ft <br /> _ Eanvadon b dimNmr q Open Balmm O GravN Pack/UnHd Sim—RI diener <br /> q UnRUH, mr Caain3 Indiemeter / CaMucmT CaNng Depth ft <br /> WNICmIng Dleb -1/In ThickveavCnup/ASTM� a/O 0Steel yPWtic <br /> CroutSe] Dryth R-/// ft .,/Net CenBnt 135elnlm Steel (3 Can, <br /> /1 lPIlAbVlid-lOgolwarerl OSMM Cmnenl s®keds/7plwale <br /> ❑UNNj N mlida) 13Mavuhewe5pe;xaolld+_x Namc <br /> Groat Pbamenl Method ❑Pum Flee Fall q Otber13SPm on Hle O Spm Sublmned <br /> 13 timer,r t/AwJgayr(Warne) <br /> PEDESTAL Inrralled By •�pnikemr r gPump Contn13Oth <br /> Concrete PM..i Dlrr i-_ widen-.- <br /> R B Thick r/ in 13 Cbdary Boa SMw PI <br /> PUMP 13 Submembk q Turbine 13 OVIe <br /> WELL DESTRU,,TION HP__ Pump Se--B SWding Waterl.t ft <br /> ❑Open Banom q Cnvel Pack ❑Unrated 13 011ier <br /> Well Diametc_b Tth ft Dcth <br /> Subg Mid,rhd 13Nut19Ilb&'/S-/Og/ 0Sad C., <br /> 0 BemUiM(20% lid,) 13x x _ safl k TgtrC/u7inpB lm w <br /> 4Perfim13mdBmRmbnoe­F <br /> um fl <br /> b_ft <br /> Nene <br /> ri.H M H Me Wd 13 Pumped 131.Pall 13 other 13 spm w File O spm Submitmd <br /> q Compbde with Mush..Cip bNov'IRM 13 rm m ENeing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORT(WILL BE DONE IN A &OR SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATION& I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN C <br /> WORKERSCOMPENSATION LAWS. <br /> WVP/JAj'lC€MT3Y ALL <br /> MINIMUM 3�4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 1{�C 1 N COUNTY UY <br /> Ston >!.'CJAlli9C TTTLE��"ECLO K7 DSAN ttPNOAOUIN <br /> 1 � <br /> d <br /> DEPARTMN tY "w.•. .. <br /> _ <br /> AppliadM AcekpmdB _ p�u <br /> Grow Ivpecdan By De¢ O EDA,,, <br /> ❑ SPECIAL�Well PIPOTH OD 01 <br /> Pump InEpection By Dem ❑ YYAIVER Re[elYed / <br /> DmnRcrion Inepeclim By lib <br /> Cvnttrvchd WNI Dopik p <br /> COMMENTS W <br /> E SC Rieelved h Amount <br /> Coda Info B Cub RetRRUni a4 hrmlV <br /> 6erNee 0.e Deeg IRvalccM We111DM <br /> UHO1212=tl <br /> w.uTn wATDt nTxt rERMrr <br />