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SAN JOAQUIN COUNTY ENVIRONhIENTAL\ ,'„DT,ART ELL/PUMP PERMIT <br /> NON-REFUNDABLE �I, 304EWEeERAv¢3 TOCKTON CA 95701 -CM)66S-3420 <br /> PERMIT C / CALL 209 953-7697 FOR INSPECTIONS EXPII1 YEAR FROM DATE ISSUED <br /> JoeADDS <br /> RFSS J� V . LG�g. Q.s�y �Qj q,aCJzj <br /> n G CtTY21P <br /> CROSS STREET �/NNtJ APN �r Yk�—dD--O� 8 <br /> `/ /1” /�� PAg ELSELE <br /> GWNEq NAM _�.�1] FiT/v PHONE 9 M <br /> OWNER ADORPSS yCYTYI$rATFIL]P Z �k <br /> CONTR\CT9q WG6'T r�A�/�� i_�-1T 0�g PHONE <br /> CONTMcroRKADDRESS IIL PSA- I CRV/STATr r ]� _w <br /> SUONTMCTOR <br /> PHONE <br /> SUKONTM(TOR Amuu V <br /> CI'TV/$TATV$IP �w <br /> LIccws[ ❑C-57 0G61 0D-09 thcr ) N <br /> a DA NUMEEq EXPIRATIONDATE <br /> CCOCRA%TICAL INPORMaT10N: Cpprtllp%es x Y <br /> INTe„DeDUSE e itrTpapthl <br /> P <br /> EIIT� RsngeSeclbn . <br /> W.Lr Quality AlnRaing ❑Soil Sampling/Charmu.imligr <br /> O Public Wv4r s&ym-.— 41 <br /> 41 1f4i(Arm,fiom tow eb yywm ame T� PFun—ry— <br /> TYPEOF WORK O New Wdl ❑Replacement Wcll ❑Well AlmnimJMVV,fN j,m <br /> ❑Monitorin Wel y) man-f.r-14 nump1p Tear <br /> Hol. ❑Other <br /> —_ ❑Soil RoungU) <br /> D Well OnuW: _ pu ❑Gedeehnicd <br /> It. nnnbnor6ori.p yy <br /> ❑OutOFSemice Well OOiu Erse ke Well RerNwel N <br /> O New Pump jgwum Rcolecement O Pump RepnV, ClCrwa-CprmMian Repair <br /> WELLCONSTRUCDON <br /> Drilling Mutant O Mud Rotary O Air Rotary 0 Auger D Cable Tool O Push Point ❑Other <br /> i PmposW Wall Depth 11 Excavation indiamear ❑Open Bottom O Olavel Peck l Garel Sia__in d"ummm <br /> ❑CondtKt.Caving m wto <br /> o amemer / CoWr Casing Depot R <br /> Well Caring Dumeter_in Thicko SVr GaugyASTMScHd ❑Steel OPluoic ❑SUlnicar Steel ❑Other <br /> Groat Sul Depth 11 O Nm Cement(w I6 hug/J-10gdw ',) OSaM Cem.m <br /> ❑Rentovrxk ram/T 7gril gel weer <br /> tdve CLO%solids) O Manuhclumr Spec%solids_% Name_ ❑Spee at File ❑Specsed <br /> Crows%aTrmeM Merbotl OPumpcd ❑➢ra Fdl ❑Other OR..rden[/Aecdentor(u.) <br /> j PEDESTAL InHdled Sv O Drill. ❑Pump Curna.or 13 Other <br /> D Concrete Pedeual Dimension: WNth 11 Length R Thick in ❑Christy Bpa OStave Pipe <br /> PDMP 0Suln,xieile ❑Turbine her PamPSety,0_R Sundins Vinuo Level fl <br /> WaL DesrRurnon ❑Open Bmtom ❑Gravel Pack ❑Unceacd ❑Otho <br /> Well Dr..,_in Total DepM 11 DcpthWWatm R O Casingmb Pa'mtW Rom Rm M1 <br /> SeaMaterialg Material ONeer Cemcm(94 Th Eng/5-/0 gu/wwer) ❑$and Cermnt_ewF my/7µlwu, O Bemmmite P.H.tc <br /> O Bentonite(2W.solids) ❑Maw6uturm Spec%solids__% Nem. C3 Sp.on file ❑Slices S.NoNcd <br /> Plscemeot Method O Pumped O Free Fall D ghe, <br /> ❑Complete with Mushroom CapR blow 1pad O Complete to E.Vr2 Su .c Petl <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME 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 /> CURRENT <br /> COMPENSATION WITH <br /> 0 HOUR ADVANCE NOTICE UI ED FOR INSPECTIONS ^/ <br /> SIGNED TITLE DAT[ <br /> ------------ - <br /> 5 !L <br /> BEPARTMENT/U1�SE NLV ' it <br /> Application A.cep[ed By IJ UAAy Dw tirF' ' � AM G Employce[DO <br /> Oro.lupmdop Ry Date ❑ SPECIAL Permit <br /> Pump Impa[in By Data ❑ WAIVER Received P7 <br /> Denrucw.Ural, [tan at” Dine Construetw Well Depth H <br /> COMMENTS d <br /> a <br /> d <br /> F--PE--T AnmuM G6ChumRecely. Date Permit/ <br /> Inf.f o RemlEtetl B Se Ire R west p Invoice M Well IDN <br /> o °O 131 0 3 <br /> San= a7Ai �/.-(/yr ASTRW PERMIT <br /> i !YTjv'' /1/!7/LG C ((�/1,`'/fir <br />