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� p9 0-3 <br /> WELL/PUMP PERMIT 6,1s6a '- <br /> - of <br /> SAN JOa9UM COUNTY lWnMVrtAl.yriN DVARTMwr M E WEpEIt AVE J',..O, TOX CA PSM-(M)Kh420 <br /> NON-REFUNDABLE PERMIT CALL 2(19 95}7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> S f r TW <br /> Joe ADDRrss Crlv/Tir S"7t.,Cer� / 95106 <br /> �1 —� �r� 0y <br /> CRORS SERELT /�nr/.^ /..�..- APN "�rp/EPARCLL SIrlJi'LLAnD USC APPIJGTN)NM F <br /> O Malls �L •`v'�+B Pitons <br /> OW ADDRIIO CRY/SraT 1p <br /> CO (TrOR PNME C:LOfs) 9Y6'-/S1is' <br /> CDX (7P(ilt ADORIM CrtY/RTATEZP t>e%fb, [e 91.7or <br /> SUECONTE oit PHONE <br /> ` <br /> SDEC()eft IpR ADDRFM CTr MATEJLR <br /> LIC[I'ISE CIC-57 0C61 OD-0 ❑Olke NUMBER �/� EEPIRATION DATE /2 S/ a <br /> GPACRVHICAL INMPMATION: Coerellnla X 27-90 0/1/ Y /]/- 1Y 0J./ TowmDlp_ ReW Seetlen <br /> INTENO[D USE ❑DorrcancTnvatt ❑lrtigatiWAgricultural 13 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chatectenatioe <br /> ❑Public Water Syeterit <br /> U uffa—1 fiom D`xr w Yr¢m ame ovenN—aw Move;Wn� <br /> Tve[OF WO. ❑New Well ❑Replaemlent Well O Well Altcreioo/ModiR 6.o ❑Other <br /> ❑Monitoring Well(.)-----#of,eell. E3 Soil Roring(s) aarteeea �E!Gwtahnical�sosa°'Nm <br /> ❑W,Of--Beni.Well ❑Out-0f-Service Well Renewal O CrosConnection Repair <br /> O New Purup ❑Nrnp R kcenNnt ❑Pum Relai, <br /> WELLCONSFRIICr10N <br /> Dellling Melhnd ❑Mud Rotary Cl Air Rotary Auger ❑Gbla Tool ❑Puah Point ❑Olhc <br /> propeed Wall Depth s-sO R Esuvation1,1'!� indiamder (3 Op.BuM. ❑Gravel Pack/Gnvtl Si. in diarnmr <br /> ❑Cubluctor Casing indiarmer / Colaluemr Casing Depth R <br /> Well Casing Diam ure _in niclmedG uge/ASTM Sched Cl Steel ❑Plead. ❑Stainless Steel ❑Other (� <br /> Gro.,Seal Depth ft IXNut Cemet(941b bW/5-/0 ge/I«xer) ❑Sabl Cement smkm&17pl <br /> ❑Batonim(JW,Wide) ❑Manufacturer Spa%solids % Nam ❑Spas on File ❑Spa,Submin y <br /> Grout Pluemeat Methbl ❑Pumped ❑Free Fall ❑Olha ❑0.euNant/Aaalmmr(oa .Bost- Cve ilr.vCri sF -F' <br /> P[oesiAL IesWkB BY ❑Drilla ❑Pump C,y,Uatw ❑ Olhn 1� <br /> ❑Coocra4 Prdmhl Dim.No.,:Widlk R Length R Thick in ❑ChrWy BOE ❑8mve Plp y <br /> PuhtP ❑Subme sibk ❑Twbioe ❑ONer HP Punta Set ft Stabling WMer Level R b <br /> I 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 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS SPATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS -1 <br /> PENSATIO <br /> M IMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> 910N[D�f Bw� Tel. DATE OI RSO�O <br /> A <br /> r <br /> -E Q11 <br /> I1, r I I I I '. I . <br /> N <br /> 1 ' <br /> ,/y/I DEPARTMENT USE ONLY <br /> Application Accepted BY -"r"- Date 4 3o DSS Area EmPloya IM `s LI V ( n <br /> �eetiov B <br /> Data <br /> L!J !/l5� O SPECIAL Well Permit c' / <br /> Pump lnapcction By Date 0 WAIVERRMOVed <br /> Coasiructed Wall Depth R <br /> COMMENTS <br /> PE W RacelveE ChakMJ Amwnt am PerMU IavoleeM Wtlllp <br /> Cell I.& B Cask Sella uatM <br /> 4elt, <br /> . a R'ELLrUA@rF11MIT <br /> IT/1e0. <br />