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WELL/PUMP PERT a <br /> MI <br /> SANJOAQuot CO1 v ENVIRONMENTAL HGLTH DVAITM[M' 304EWUMAW 3-FL-STOCATONCAPH,2 -(309)46-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> ,BRADD.rJg y(/BYO/o N. GoC wff fl2El� 2ppp <br /> Ca., <br /> Gopl 95-J4�0 per/ <br /> CROsslimm //LUe I'L APNOSI- /LO-,J� PAlemsl r�`V"—LAND USE AIPIAOATWN. 9ft,0 <br /> OWNLRNAME aTALW7 L4/4r7 r7< PHONE <br /> OvIERADDRESS I?D/O Al. GOCfdJr TIES tW Cm/STATTZIP W'0// Cl/- 45- <br /> CONTRAC/OR IUE/L O t1yVdGSPhDeJ�-iQ- oc � /.UG PHDNR 209--3G�'}rj_( <br /> CONrRACrOR ADDRIST 902 /Ntle4� J 6a.4V CrIVISTATvztP LGIO/� L6)e 9S-Z40 <br /> SLIWONERACTOR <br /> Pxolve <br /> SuOCONtRACTOR AODRres CITY/STATEMIP <br /> LICETtsE C-57 O C-61 D D-0 D Other Nums" ( 904 ExmuTTDN DATE <br /> GEOGRAPHICAL INFORMATION: CoerdiftW X Y To...blp_ Re"ge_ Stelbn_ <br /> INTPNnTn USE O Domrsde/Prrvale O lrription/Agricuitursl D Industrie] O Water Quality Mothering Soil SvnplinyChvacwriter. <br /> 0 Public Water Ssya�1ccmm <br /> Ir4Nprmtrmm Owe: W.S..go.— <br /> TmOyWom 0Neu,Well OReplacementWell OWell Altmtion(Modification ❑Other <br /> D Monitoring Wells) Nof oells 0Soil Borio s adbouo' T sorteim, <br /> e() at eomchnial ' <br /> D Out-0f-Service Well 13 Out-0f-Serviu Well Renewal O Ctoafnnnecdon Repir <br /> O New PUMD O Purne Replecurn.t D Nerp Repair <br /> WeD_CpnRrRutTroN <br /> D,Mleg Method O Mud Rotary 0 Air Rotary ,p Auger O Csble Tool ❑PUTh Point 0 Other <br /> Proposal Well Dep th/O—/S R Euemdon (ain diunac 0Opri Bwom 0Gravel Peak/GnvU Smin diTmeter <br /> ❑Conductor Casing ineiameter / CoMuctar Gsing DepN R <br /> Well CadK Diameter_in Thlekncu/CwugdASTM Sched D Steel O Plaslic D Stainless Steel D Other <br /> Grout Sed Depth R O Nast Cecut(94166eg/5-/O gal Sorer) 0Stud Cmmt .rock ovT/7 gel water <br /> D Baemnke(20%solids) ❑Manufacturer Spec%solids_% Neme SO/L [NTjhK! D Seta too Fik D Specs SubminM <br /> Grout Plueeeest Method DumD Pped Frau Fall D OtOtherD Retudent/Ac..Imor(Mme)EMISH ^ <br /> t ' <br /> AL IomBed By 0 11 ❑Pump Cootmetm D Other C <br /> ❑Ceourete Pedeml Dimemkna:W dth R LengthR Thick in D Chddy Bos O Stove Plpe <br /> D Sub...-ble O Turbine D Otha HP Pum Su R Standing Watu Leve R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION 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 I AM IN COMPLIANCE WITH ALL 'S <br /> WORKERS COMPENSATION LAWS. p <br /> M [MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Tiner//e//g�cr zCAj,6a- DATE 3-13-01- <br /> _ c <br /> I�-�f <br /> Li i <br /> 12 ` ENdui Rd 12 E"I.,Ra <br /> J r <br /> l <br /> 7 N q U <br /> p <br /> — -- - J Ill <br /> DEPARTMENT - <br /> APplicadon Aoeepsrd By 1 a4-Y Dsfn A18E- NLYAm .•p -employee ION I lfy <br /> Grainlospecdoo By Date O SPECIAL Well Permit <br /> Pu II I By �wto O WAIVER Received <br /> COMROe1ed W I/D��Wb yy R <br /> COMMENTS�y <br /> � P � <br /> PE SC Received het A..1 Do,. PermtH Inw1oN Well IDN <br /> Codes for. B A Reedtkd Servk.R tortM <br /> b 8 B <br /> IIKDQ LKe WTILIIINI PExtArt <br /> tatruns <br />