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WELL / PUMP PERMIT <br /> ,AN 10k6hJIN COUNTY 1F.4-11140NMfisl Al HEALTH DFPARTMF.%T 304 IL WEBER AVE 3"FI.-Sr <br /> NON-RFIF(IS-DABLE PERMIT CALL(209)953-7697 FOR 1NSpLCTIo%S EXPIRES I YEAR FROM DATE 1S%-%1 <br /> JOA AT)rjkF-',S <br /> ('R0qqSTRFFT LF2 VOCLI AF'NDP,3- jf�pp, j7iFpRCEL SJU LAND USE A PPI.IrA TION <br /> 0"NER MIME <br /> 0%4NFRADF)RF.SS,. <br /> CON I W^CION <br /> ft!2 AIJAIW 174.5, 7P4 <br /> C014TWACUOH AmmmsS Crn.STATEIZIP <br /> SUBCONTRACTORPHONL <br /> SUBCONTRAcrOR ADDRIEss C1'1)7S1A1t.!Z1P <br /> Llcc,Nsu 0 L3 l P I Ll v-0 El 0111v N' thiBER LAVIR411t)-4 DATF <br /> Criardinatr% X Y­ Townshlp _ RRnRc <br /> i7l_enV_VIUSE mc�tivrlrivatc E In6nind C1 Water Quality Muniluring 11 Soil <br /> 0 Puln.lic Water S?,Stcm <br /> r <br /> Ll dircrew viii )--im: wdLe-r5.,.1cm Norm Cc.,)m:l Nan)t Jr J+r-777,..L" <br /> Tv"OF WORK Okl-We'll n Repl;wpmeel 14',11 Cl Well Alit-h4m,Nl udi Fi L--u lion 0 Ics,140'e 0 other <br /> C3 Monitoring Weill'3)_#of wC115 C3 Sc,:[Borig(sl. a bk­11w) 0 Geoticchnica! Kv,112; <br /> 0 Well Lk:m 1`11C.t I Lill 13 Out-Of-Service well LJ 0u1-01_-Service Well krne%st <br /> ae+-Q-.piln-'r 0 Pump Repluement 0 Purrij)RrrAiT nCruss-COnneclion Repair <br /> WELL CONS]kUCHON <br /> Drilling Method 0 Mvj Ru7,ry .1 Air Ruta*} 0 Augerp1q�- _,Focl 0 Push Voint 0 Other <br /> Well ell Depth fk YF411dL1.on iT.larrztc-T W94en Batu m' 0 Girsvel Pack-'camel Sits in <br /> El CUTIdUOU,(a ng <br /> in4dioniclet I CionducturGibingDepth <br /> i`- <br /> Well Casing Diattic;rt In Schell_af? 'jpmkoc 171 Mastii; 0 Stainless Steel 0 OLhct <br /> Grout Scul 1)cp1h -o-% r) C1'Neat C:vnrrA;14 16 bag, Y.Wev) d Cement xfjc�m.,r:7: <br /> 0 EICI EUfae 1,20!,1 6 ils 1 C3 h1amAdvtowi Sp"0.t wl,i d 4 N41=.- • cl sprcs an [-fle D Specs Sul <br /> Groul Placement Mclhod cp@f4lvmpc!d 0 1'rec Faij 0 Other_ T3 Retardant;Accelerator(name) <br /> PEDESTAL jfkl(vllcj fit 0494ARIL-7 ok"M-IF UL)r.tL�,cjcr L3 Other. <br /> ncrele Pedmall 'A-id:h_4 fl I n Thick in 1-3 chriwh Box 13 Stove Pir <br /> ;PLI.mp d9;:&ubrr.-=iib!c [3 7urbinc 0 Other. F 0 p -i Level <br /> =SL5 <br /> I IIEREBY CERTIFY TIIAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE 1)()NE IN ACCORDANCE VATTI <br /> T I N". <br /> JOAQUIN COUNTY ORDINANCES, STWN <br /> ATE LAS, AND RLLFS AND RECULA 0 S I ALSO CERTIFY THAT NIV REQUIRED LICEP <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CO%TRA(-ToRS STATE LlCiNsi lJOARD AND THAT I AM IN COMPLIANCE WITJ <br /> WORKERS COMPENSATION LAWS. <br /> N1 UM 24 HOUR .ADVANCE NOTICE UOUIR ED FOR INSPECTIONS <br /> DA I t. <br /> t I I I I <br /> L/ <br /> �vit L <br /> I <br /> i _ =FFIT <br />