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WELL / PUMP PERN11T <br /> SAN JUAQttIN CDL'NTY F%%IRONMEN I Al.HEAI.TII D1.PARTMRNT 304 F NVETI R AVE 3"FL-5'IOl KTON CA 95202 - (209)Q <br /> NON-REKINDABLE PBRNIIT CALL 12091953-7697 FOR INSPF.C'TIOl S EXPIRES 1 YEAR mom DATE ISSN. <br /> Jolt ADDRESS N (—_1'T�rYYLIPlu� <br /> CROs STREET _A PN F;,JI/�- � '.—PARC 11.ti17.F. I �" j_1 AtiU IISF.APTLIC•ll'tU'�'M_ _ <br /> 0WN1.RN.&ME _- WIn PNt1NF. - _ <br /> 1 �' r C� <br /> C1Tl`/STATE1L11' r��L� y <br /> CON-I RAC.TOR . + ( PHUNF �nQ ��^I� �lilJ`-1 <br /> CONTRAI-FOR ADDRt.i4 LJ t11 J7�1n _ C'1'1'N'1S I ATr rZIP <br /> ShBCf1NTRACTUR _- --- PHUNt -- _ <br /> SUISCONTR.&C'MRADDRF.SS _ __ CI'1'Y�S7AT'F.fZlr <br /> Let ENst. ❑C-57 ❑C-61 ❑D-09 ❑lhhcr _ \1'MDER _ _- EAPIR4-110N DATE _ <br /> GEO GRAPHICAL INLORN14TION; Coordloates X Y ___ Township Ranfe S"IWII_ <br /> INTENue1i 1!SL ❑D,.,mcstic:Pnvate 0 lrrigptwLA�.;i;:u:tural ❑Industrial ❑Wmur Vualitp Alnniwr g I]Soil SamplrnbC'haraGleli7: <br /> ❑Public Watcr SN-stern_ <br /> LIf d'.IRmil from b h ner e:Crz`>air n arn� - Co'loci are nr cm[ u iiFi•i <br /> TvrE Or W'ut+K ❑New%kell ❑Replm+:rment Well ❑W%;!l Altcranunihltxlification ❑Test Hulc Cl Other <br /> So <br /> a of hn nN ❑Gmrethni�a) h of lmrin�;; <br /> ❑h.onilUrinR V1c1:i;) x of wells O 5 it Aoringfx) - <br /> `CIl Destruct on ❑Ohtl-Of-Cer"cc Wcl'. O Ou-.-OF-Service Wd!Renewal <br /> Q New Pamp ❑Purr Kr laccricnt ❑Purrip Renoir ❑Crnss-L:unnea::ion Rcps:r <br /> 'LLL CONWRUCTION <br /> NYLL ug!Ylethod ❑A1ud Rota'"Y Q Atr Ru:ary d.Auger ❑Cahlr Tool [3 Pash Paint ❑Ulher_ <br /> Proposed Well Dq,1t _fl Fxu,,aliva to diameter ❑Open Bottum ❑Gra+cl Pack.;lir+v<'Sim in; <br /> ❑Conductor Casing in dtamctcr Cund:,tor Casing Ue}uh _ fl <br /> Well Casing Dismcter in Thtcknesti'G,cupc+ASThS Sched ❑Sten ❑Plactic ❑5131111055 Steel ❑ <br /> Grout Seal lh•Iith_ J_ ft ❑Neal Cement(94 1.6 b4jg/S-10 bat uvIer) ;�4and Cemrr-t scr:k m;c <br /> ❑Rcnwnitc(2-,o sul•ds) ❑h'.anurit,'uter Spec r!'„solids % Name _ O Specs an File ❑Span Sul <br /> Grout Placement Method ropumpoijj ❑Free FELL D tither ❑Retardant.,'Accelerator i name) <br /> PEDESTAL Inglalko By ❑DnIler O P,unp Crntrsctor ❑Other _ <br /> 11Concrete Pedestal Dimensions: Wi:11h fl Lrngth ft T-hick on ❑Christy P41 ❑Stove Pit <br /> PUMP ❑SnO111CC hle ❑T.trhrnc ❑UIFcr lip_ Pump Set _ ri Standing Wiener l eve! _ <br /> 1 HEREBY CERT IFY THAT 1 HAVE PREPARED THIS APPLICATION AND TIIAT THE WORK WI1,1, BE DONE IN ACCORDANCE ':VETT <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFI` THAT MY REQUIRED LICE' <br /> Cl'RRENT AND ACTIVE WITH THF. CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I ANI IN COMPLIANCE %MITI <br /> WORKERS C0.%4PENSATION LAW'S. <br /> NUIR LIN] 24 H(.)l!IZ ADVANCE NOTICE REQUIRED FOR MsPECTIONS 1 I , <br /> T + <br /> FN <br /> I An <br /> I 1 <br /> _ t <br /> I <br />