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WELL/PUMP PERMIT �/�'� <br /> SAnaWQUIN COUmm ENVIRONMENTAL HMLTH DEPARTMRT 384E <br /> JE WEBER AVE 3-M-STOCKTOn CA 95303-(21,)46S U,HI <br /> NON-REFUNDABLE PERMIT( ICALL(2209)953-/7J699J7 FOR INSPECTIONS /EXPIRES 1 YEAR MOM DATE ISSUED <br /> JOB ADDREBC Q 31�F (I/jL.= . CTIT/ZIP <br /> 22 <br /> CROMSTRECT APN �J-/�' /YARCELSIZ83y 21 WXO UCCAALI�CIATIONR �r A <br /> OWNElr NAMt I PHONE I/ • eYfq/` <br /> OWNEE,.. /qh�O 4. Crl'V/STATE/EIT 'W • /5�— v <br /> CDN�NACEDR n MrP/j , ✓ pEOIrE y 5 DH <br /> CONIAALTORADDREBC 5CIIIV SrATE/LP 4 <br /> SUBCONTMROR PHONE <br /> SUBCONTRA RADDRLRS CHT/STATVIJP <br /> LICENEC C-57 IJ C4I 0D-09 ❑Other NUMBE0. E%FlMTON DATE <br /> GTAORAPNICALINPORalATION: Coordinates X Y Township_ BEEBE� Section_ <br /> INT•wm•^•te. Domeolc/Privsa ❑IrrigationiAgricultuW ❑Indmtdd ❑Water Quality Monitoring ❑Soil Searpling/Charicteriation <br /> ❑Public Wata System <br /> If AQeatNweWw_ Ew Y•Rm .°' tint rnNw _ ._ r��. <br /> TYPE Of WORK PlIfjNS.Well ❑Replacement Well ❑Well Altentine Mne ifiution ❑Olbar '`L <br /> ❑Monitoring Wdi(s)------Aofwellm ❑Soil Boring(.) "'N'hNa ❑Gmtothnical xorm,o,P .—.c1 <br /> ❑at-0f-Servicc Wcll ❑Out-0p-Service Well Renewl ❑Cmsa-Conisation Repair <br /> w Pum ❑Pomp Rcplaxomm ❑Ptimp Repair <br /> WELLCONMIx::DON /7yN�� <br /> Drilling Methal ❑Mud Rotary ❑Air Hoary E)Auger tLY('Wle Tool��N// ❑Puah Point ❑Other FTt <br /> Pna,md Well Dryth ft Excavation in diameter RlZm7 Bottom ❑Gravel Peck I Gnvel Sire in dammer 11' <br /> ❑C for ing indiarecter / Cooducbr,Ceti,Depth R <br /> Well Cashel, Diameter tar Thiar a to Gauge/ASTM Schad)Q -/L [eel ❑Plant ❑suimkM gtal ❑Other <br /> Grout Seal Depth R ❑Nut Cemeist(94 fb bag/3-/0gaf Rorer) and Ccmrnt/a T2 s.aarx/7gdwatu <br /> ❑Bentonite(20H,solids) 0Menu1ac[unr Spec%solids % Name ❑Specaon File ❑Spens Submieod <br /> Grout Phcement Methodi5b4oaroped ❑Fra Fall ❑Other ❑Somnolent/AccdeMar(name) <br /> UnUAL las I By C64tiller C3 Pump Comonewr ❑ Other <br /> ❑Concrete PedeMal Dieraademi WMth ft Length RThick io ❑Chdsty Boa ❑Stave Pipe <br /> PUMP boRnible ❑Turbine ❑Other HP Pump So RSMmRog Water Lwel R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATIOK AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <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 /> IMUM 24 HOUR ADVANCE NOTICE/REQUIRED FOR INSPECTIONS <br /> Santofi�- ( / -- DATE <br /> I IT 42 <br /> FFF <br /> O E qv 10 M <br /> T O P <br /> vv DEP ENT USE ONLY <br /> ApPliutim Aa �- 2 -- San. u,, Am_... EmpToyeclD# <br /> Genu[Inrpation y Date-- O SPECIAL Wdl Per111ft <br /> Pump h apatien By ®• 0.n�2�/ 0 WAIVER Rewelved <br /> Cm anavled Well DsptY R <br /> COMMENTS c- 3.50 - v <br /> PE 8C Reedvd Amount Data PaMU Inrolesd WNI IDE <br /> Cedes Info B ash Rallied S.,Vioa ,I <br /> (Q z- Ro u o <br /> U o s'U Ic g z Y <br /> run Cr 0}446 WELL PVTIP PFAMR <br /> /37nai <br />