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WELL/PUMP PERMIT y� <br /> SA.IJOAQL'NCOI'NTYENTIfto%*%NTALH' 'IUDEP.kR lkNT E 16FT 114EN STREET-STOC:TON CA 95202-(1-09)668-3420 <br /> NON-REFUNDABLE PER1t11{T� n / / EXPIRES 1 YEAR FROM DATE ISSUED <br /> 709 ADDItLSS UA1L�C I /T V�2. !1----- / -----" <br /> V CnIiLP <br /> CROSS SrRELI" _s`±�t�-dl� ' <br /> APV�� � P.IACELSIZE, S_ x <br /> OU'Lit Nmm �..Q..-L_. (Ilr itoNE 96F-799-3 <br /> 33 // �J <br /> OwnER ADDRLxS ��' UX 2 _ CITY/ST-1TE/L1P TOL-tG1y�� C)-/J �SZ �7�I ' <br /> CONTRACTOR _ ( P1101E <br /> // <br /> CO,m%C-1OR ADDRESS 07(12 . 727_ CI n I'S TATVJM&F <br /> �IKONTR.NCTOR ____ _ PHONE <br /> SEKONTRTrTOR AI)DRE55___ CI7l/SrA rTiLP____. <br /> LICENSE GC-57 D-0 ❑Other NUMBER ExnLmON DsiE <br /> GEOG0.kpui Otxodlnare <br /> ?( tTaw'nshlp_ Range Seerbn___ <br /> INTENDED USE ❑Domestic Pn.ate ❑Irricauon A_aricultural I C A'mcr QDaliry M minting ❑Soil Sampling ChL"Ctcrisation <br /> ❑Public Winer System i <br /> IldJtiT�u bcs.O»uc:: -__ ._— Ws.Slunm Noma C—N— rw.NucMt <br /> TYPE OF WO" G New W"ell ❑Replacrment Well ❑Well Altcnti x%,Modificwion ❑TLsi Hole ❑Other _ <br /> ❑Nim rormi;Wells) .<. ❑Sail Bori "omo.r"r'"'i ^r <br /> 13'A c I I Dc Amw ion ❑. m-0f-S��ice WcN G Out-0f-Sax ica Well Rcncaal <br /> eu- ❑ R Q <br /> I.-M.1 D R. v ❑CnnsLtivn�tion R, r <br /> R'u.L Mm <br /> n <br /> Drillingg Method ❑Mud Rolan' G Air Roulry C1 Ager G Cable Tool ❑Pcsb Poim G Ottk-r_ <br /> Proposed W rH Dinh_—_ft Excasitioa in diameter ❑Open Bonom G(;m%cl Pack,Gravel Size vt diameter <br /> ❑Conduvor Casing in diameter / Conductor Casing Dcpth R <br /> N ell Casing Dian icter in Thiclnes.'GaugaASTM Schell _ ❑Sscl ❑PI"ic G SraiNe<s Steel ❑Other __ 4 <br /> Grout Sell Depth t7 ❑Neat Ccn=t;SW lc 'J-10 - vterl ❑Sand Ccrrc:m_ <br /> - Sa'' suck mic�7 sal walcr <br /> O Bcmonnc f 21Y_e solids) ❑Mawfa-urer Spa•>soiid<_ N a x G Spas on Fil: ❑Suxs Sulinuncd <br /> Groat Plaeemeat Nlelhad ❑Pumped ❑Free Fall ❑Other ❑Reard=:Aceclenator Inyvel I <br /> I PEDUq IL Ipatillesf By ❑Ordfer G Pump Coat w.w ❑Otho -- <br /> ❑CootrNe Pedestal DlmeaslaDs: Width_R LengM_ft Thick in ❑Chrhty Box ❑Store PI e <br /> PL'SIP ❑S�btrmiblc si Prbinc ❑fhher HP ZJO2_ Pump Set�7�rt Sanding Water Lxlcl li <br /> NVLu DtsTRLC.TION ❑Open Bonom ❑G—ol Pada ClL—ou ❑O,he _ <br /> Well Dumwr_in Tarsi Depd+ H Dcprh to N alcr _it ❑Casing to be Perforated from__ft w A I <br /> Seallog Material ❑Ncat Cemcm!pI Ib bag.J-10 wl.area/ ❑Sand Comm-, rack mL- 7 ga!.alar G Beolanitc Pacu —_---� i <br /> ❑11-1-ite 12(Mn solids) 13Mmufzcuuer S r.4 solids „ Kamc <br /> F ❑Spec on Ftic ❑Spe"Submu"d <br /> Plxernent Method ❑pampa! G F—Fall 11 oft, <br /> ❑Co Ito.ith Mushr Cap ft bcloly --- G CompLmx m Existing Surixc Pad <br /> 1 H£REBI"CERTIFITHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK%%ILL BE DOVE IN ACCORDANCE WITH SAN <br /> JOAQU IN COUNTY OR4NkNCE& STATE LAMS•AVD RULES A.\•D REGULATIONS. f ALSO CERTIFY-THAT.%n REQUIRED LICENSE IS <br /> CL'RRE\7 AN A W ( CALIFORNIA CONTRACTORS STATE LICENSE BOARD A-ND THAT I AM IN COMPLIANCE WTTH ALL <br /> M'ORCHRS Cyf 7 <br /> . D TITLE DATE / <br /> q <br /> 3D <br /> JG 0 4�' <br /> hatec'wj��MF�� <br /> ------------ <br /> I IT <br /> fy� <br /> DEPART'IIENT NLY <br /> .Applic-Akm Accepted By. Date Am_ EnWioyee IDA <br /> Grout Inspection B, r Date PECIAL Well Permit <br /> Pinna lnspcxxion By__ 1 _ ilate <br /> WArvERRecdved <br /> Desnucum inspection.By Elm Consumcred Well Depth_ h <br /> COMMENTS <br /> PE SC RcedPed AmeR�f <br /> Info Rte Date Sano Invoke M We!my <br /> I <br /> MID 43-02J006 WEB Well Pa mr end Dzarauon.� <br /> 9:11.2007 <br />