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WELL/PUMP PERMIT } <br /> SG -iED <br /> gAX JOAQUM COUn'rV ENVIftONMEMALHGLTH DCPARTNa'1' ]BCE WE9ER AvE3 nPLRTON CA 93L12-(2h9)dhgJC20 <br /> NON-REFUNDABLE PERMIT (^ CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADMU40i Lone T-8 cl-alp C? <br /> /^ 2- LCLO-D7 P..L St.. <br /> S-S LAND Use APPWunoNp <br /> 00.085 SieeCT l +-C7It APN <br /> - 1 e\ ry PRRNC �T)l55 —�IbR <br /> OwnLR nAMe ((}} <br /> OWNER ADDRESS '19 Ills E <br /> CONTRACTOR 1 �jP.. <br /> CONTRACTOR ADDRESS �99G+-2-1.1, <br /> 14G!i(a <br /> h clTnwATE21 T-1% � <br /> ybn A 9_J S(' I <br /> SUBCOWRAC OR PRONE <br /> Stnum IRACTORADDRESS CITY/START IP <br /> LICENSE E3 C-57 E3Cbl E3D-0 X1her l_1 V NumstA LOZ 1 O ExPIRATION Don C7) U <br /> GXo BAPInw.IXFORMATrON: COONioata X Y Towuehip_ Range_ Sandal_ <br /> In'rervDEo USE Domulic/Privwe ❑ImIlmodAlvem ml ❑Industrial ❑Water Quality Monitoring ❑Sol SampBnF/Cherwrerintion <br /> ❑'Public Water System <br /> '� IfaiRnmt nom Ownm. w Yom ems nmt wsm <br /> T OFWORR ❑New Well ❑RWIanonent Well ❑Well AlmmtloMNdifiafion ❑Other <br /> ❑Monitoring Well(.) Mofwdls ❑Soil Boring(a) xofbmiop ❑GwtwhnicalambwlnR <br /> ❑Our-0f-Smi<e We 1 ❑Out-0f-Smite Well Rrnewal O CreaeCcemmen Repair <br /> ❑New Pum R lacrnrent ❑Pum R <br /> W,UC(nlMVCTlon < <br /> Drilling Method ❑Mud Rotary ❑Air Rotery ❑Auger ❑Cable Tool ❑Push Point ❑Othtt <br /> Proposed Well Dcuh ft Excavation in diamwu 13 Open Boham ❑Grovel peek/Growl Sia in diameter <br /> ❑Conductor Cesing in diamNw / Conductor Casing Depth B <br /> Well Caning Diameter_in Thiclmas/Creuge/ASTM Schad ❑Steel ❑Plestic ❑Stand.S.1 ❑Otho <br /> Great Sell Depth ft ❑Nat Cement f94 ID Dag/5-10gol wmer) [3 sand Cement Sark roe/7gd ower <br /> ❑Banwa a(20%wine) ❑Mwuumamr Spec%solids % Name ❑Spee on File ❑Spea SubmiDW (- <br /> Grom Placement Method ❑pumpd ❑Fres Fall ❑Other ❑RwardanU A<Netwar(name) C <br /> 7 <br /> P�pr f�tw <br /> day ❑Drilta ❑Pump or ❑ Other R <br /> ❑Covcrtle Pdeehl Dimenalooe:Widthhith a I<ngN fl Thi<k iv ❑Christy Bos ❑Stov<%pe <br /> POMP ubmetsible ❑Turbine ❑Otho HP pump Set ftSudivg Water Leval R <br /> 1 MR BY 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. 1 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 COMPEN TION LAWS. h <br /> MINI M HOUR ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Tm t <br /> T <br /> D <br /> 05 <br /> DI4 C 3Uw <br /> H <br /> DEPARTMENT USE ONLY r, <br /> Application Aweptd By Deo V f246s Area Empl0Yee1DM POGO �j <br /> a <br /> Gmut Wpmeoa By ry Datc ❑ SPECIAL Well Permit <br /> Pump Inspvmoa By alt W_tVltV -' Dow $-31'-US ❑ WAIVERReeeived <br /> Constructed Well Depth ft On .e„sn <br /> COMMENTS�L(�_l/e"/ <br /> PE SC Haulyd het Amount Data Permit? InwfaB Well IDs <br /> Codes !or. Bysh emiRed Saha Ra uew0 <br /> 3-f'[ aro l3 sD.w 0 8 B7 2 <br /> • <br /> EXDuaeaa wsaLvtAseuuDr <br /> Irzraws <br />