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WELL/ PUMP PERMIT <br /> SUV JOAQUIN COUMV ENVIRONMENTAL HEALrm DEPAInmLVr 304 E WEBER AvE 3a°FL-Sl'OCKTON CA 95202 - (204)469-3420 <br /> NON-REFUNDABLE PERMIT (.ALI. 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JORA4DREffi SO /v/ `E• C PV) - CITI'/ZrP� � <br /> CAMSnTET +��U/yf�a_ A ,y(� APN C'SI' �l( L I PARCLLSVE LAND USE APRAC/A�TION4__ <br /> OWNER NAM' _C)& 1 +-�(� _�. PRONE 7 lJ -76bo _ <br /> OWN"ADDR95.7 Z&V— _ CrrV/STATFI7J► _ <br /> COWMACTOR � _�i¢�s's' ( , lti� /P..J��y3��•fy-7y/��7LJ <br /> CON7RACfUR hoDRE&i _ --_----`�, CMISTATFJ7JP_L /l!✓�lll � <br /> HURCONTRACTOR PHONr. <br /> 6{IRCONTRAK-TDR ADDRESS_ CmISTATEIZIP <br /> Lsc1.Pt0E ,4c-57 OC-61 C3D-09 OOlhcr NUMRERT??_ � £xRRAMNDATE <br /> GE-XAFK—LINMIMtMATION: Coordlaatta X Y _ TownstJp Rr+wp Swd e <br /> IIS$( 'iI0orneetic/Pnvarc ❑IrrigariWAgncuituraf O Indusaial Q WaterQmdity Monitoring f5 Sal Sarrtpling Chanctenzation <br /> Cl Public Wath System <br /> If dJ7m.A fmA.rm uv m–lTims–� --- ------- �risTT,wr�Ser <br /> i Paz OF WORK ;i0cw Wcll 0 Rcyl.cement Well O Wcll AlWation/Modificatlon ❑Other _ <br /> O MonitoringWell(s) O Soil Bors)_ soap ]Gootaehncal <br /> O Out-0f-Service Well ❑Out-0f-Service Well Renewal ❑Crow-Omneeuon Repair <br /> New PI—P D Pump Rtplwcni ❑Pump Repair <br /> �y�orsrxurnoN <br /> Drilllatg MethodlilMud Rotary O Air Rotary ❑Auger O Cabk Tool O Push Prune 13 Other (, <br /> Proposed Well Depth J ft Excavauon t�-- in diameter O Open Bottom ',ravel Pack I Gavel Size in dinrteter <br /> O Corduc/tD��Ching in diamrft' / Conductor Casiog Depth ft ^� <br /> Well Crain fTarneter0_in Thicknesc'GaugcJASTM Sched�_I? O Steel'J''4anc ❑Suinksr-•Stcel ❑Other (n <br /> Great Sea! Depth�—fl ❑Neat Cement(J4)b bay/3-/0 gat water) ,'^rLs&rd Cement a 3 sock nuc/7 gal water <br /> O Bentonite(20%.solids) Q Manufacturer Spec%.solids % Name ❑Specs nn Ftk ❑Spas Subrmnod C) <br /> Crest PhtceRseer Mt:tiod _)5'4umpai ❑Frec Fall R Otho_ ❑Rercdant/Accelerator(name) fi <br /> IQIIISTAL IRgalkd By .Dauer a Pump contractor o (hoer <br /> O Coomila Pedestal INmenalons W Wth _S Length` ft Thick in O Chrimy Hoa CI Stave Pipe f� <br /> bmemib)e O Turbine ❑Other FI p' _Pump Sd ft Standing Water Level fl <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 l <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL T <br /> WORKERS COMPENSATION LAWS, <br /> INIMUM 24 HOUR ADVANCE NOTICE <br /> �R <br /> EQUIRED FOR INSPECTIONS <br /> SIGNED lnyst�d,/NcK -- y <br /> DATE <br /> T i <br /> ( <br /> DFHT AE ff <br /> DEPARTMENT IJ SF ONLY <br /> Applicabat Accepbd By Date 11-3c'107 A. Employer 100 <br /> (Mout Inagoctioa 8 - Dau D 7 13 SPECIAL Wc{I rlrsAit / <br /> Pump Inspect. L- Date /- .O5- ❑ WAIVER Received <br /> COUBhUCted Wt-11 Depth A fl <br /> COMMENTS• Q t-4 c o T D .Qs p e lJ <br /> I'm SC Reetdvsd Mckr! ARaunt <br /> Coda 11116e a Rtadtted Dek Service Req M lnvwm 0 Well lam <br /> 'f3 -7 5 z S.✓v <br /> c( � <br /> os'. <br /> U �•7 <br /> s° "`� Po02-7a <br /> 01D U-02-0la <br /> V27Raat WELL RM PEWIT <br />