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WELL/PUMP PERMIT <br /> SJ%X JOAQULN covwy Em 1R0%IYATALHEALiu DEPARTifE�T 699$.4RrMALNSTREEt-S ocicro\CA95202-(1-0)46E-•3424 <br /> NON-REFUNDABLE PQMMrr`(�^/ EXPIRES 11 VEnR FRoa D <br /> ATE ISSUED <br /> )xR <br /> ,�I/�G✓ �/^ / t••-/�.GL1 r� CIEyIZtP GST`/ ,� R./ V t <br /> T L llbey oag 06 0 0 41 la D <br /> A� APN P.ssLEL SIEE <br /> _'�•XE6&42 4 45 {/ PW%E20 <br /> &4S "�/ / n�C�IT`Y�ISTLATFILP �/ �,�J//V�'L���/�-f !�( 7 PRON£ADDRESS Ab 766 I ✓_ 2 JIA <br /> SDIICOATRACTOR "TTT��� FMNE <br /> SUDCOATRACTOR ADDREW Ct'[1TSTATEIZlP r—� <br /> Ltcmn 0 C-37 {.) 0 D-09 0 Otbcr m m"it 5 ExPtA►TfO�DATE ZQ <br /> GE0rRAPMICALI%F,0Im I0%. Coordmeres X t 'fawasblP_— Range Swd" <br /> t1TfLitIED L'se :Privet 0 L—Agliwlttrzl 0)ndasmal (3 Wa crQuaGty Siowwring a Sal Ssmpt;Rg�Cbrauerhmi;m <br /> /V---ublic •WotrrSystem rnig _ <br /> IfdJayat 4ec:lJ+ns: mSrsmm\ems Coma ran:ur!'her vua�er <br /> TI PE OF WORK 0 Ncw Wcii 0 Rgbccmmt Weil 13 Well Almrstim►4lMilIca iw ❑Tat Me 0 Olher_ <br /> Moaittwirtg Weii(s) a•_�>.r of u:3a O Soil Borim*s) rcml T"O e D Geeaocboicsl mdzbtrat t• : <br /> O Wdl Dcamcdon D=m 1-5crviee Wall 0 Otn-Of-Smica Well Ramal <br /> 0 Naw' Reofac-meat O R. O Cror-Cormcxtiaa R. <br /> W"-L CO.Nmi cram <br /> Driln3 Metbod 0 Mud Rotary d Air Roary 0 Auger 0 Cablc Tool 0 Push Point 0 Ot!vT <br /> Proposed Well Dcpttt __P. Excavation in diantet" 0 Open Bonow O Grovel Park i Gravel Size in diatnew <br /> O Ceadw1or Casing in dWnctcr ! Conductor Caning Deptb ft <br /> ReH Casing Diatwter_in Tfirlazss=GaugeiAS7'1f Srh,^d _ Q S::A ❑Plastic O Staialess Swd 0(Alter <br /> Grout Seal Depth it ❑\catCcnreatr9Jfirdeg:'3-lOgsfaures) 0SandCnn= such mfr;7tat V60W <br /> Q Bcatonitc t2iMi;,solids} ❑Manufacturer Spec t;solids_",a Maniac O Spec ort fiiL 0 Spans Submitted <br /> Grout Placemeet!Method OPumped 13 Ftce Fall 0 Gtber 0 R-r:r&W!Acc:terwor(tante) ! <br /> PEDta7.U. IasaBrd By 0 Driller 0 Pump Caotraetor O Otter _ <br /> 0 Coocrde PodesW DLeeasloas: Width_fl Tbiek in O Cb*ly Box DStm,*Pip <br /> PL'71P 10Subrnenible 0Turbine 170(hcr _ HP PttrtlpSat ft StandingWatrrLe:c1 R <br /> WLL L DtstRUCTION a Open Bottom 0 Gravel Pad 0 vacascd 0 Orhem _ t <br /> Well Diameter_in Thi Depth__ti DcPd1 to`A=r____R 0 Casing so b0Perfwa W from fl Ioit f <br /> $env"Maeedw 0`Gear Centrist 194 lb mg:-S-In,vl raswl 0 Samd mixt 7 gal Allier G 1Bentodhe Pet"- <br /> O ticmoeitr 12D°,solids) O btanufactarr Sps�w solids :xaree O Specs on Fila. L3 Specs Sub!n ic,d <br /> Pbcvfwnt Method O P m4ycd G Fre,Fall O Other <br /> O Comptctc A idr Husbmam Cap fi below grad 13 Complete io Existing Surike Pad <br /> P HEREBY CERTIFY THAT I HAVE PREPARED TRIS APPfJCATfON AND THAT THE WORK%ILL BE DONE Eq ACCORDANCE WITH SAN <br /> JOAQ(T£S COVN7Y ORDIN•V-NCES,STATE LOWS.AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUMED LICENSE IS <br /> CURRENT AND ACTIVE WI CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT I AM IN C01V1lA3NCE%TIS ALL <br /> ICOM! <br /> SIGNED <br /> RFgYNf;�- <br /> _ cF � <br /> UN 08 � <br /> VOV <br /> y�FAgR N4 TY <br /> T <br /> f <br /> MENT L�.Y��^ // <br /> Apt:ticaaionAcaZxedBy �L/� Dole L! _ Arq 7G Et .4ryr_111? DA <br /> Gran i wmaics Drat SPECIAL Leff Permit <br /> Pomo Inspection By_��(1�iy,`St](,(.w.A_ t Dace 1o�2`l I1DZp Q WAIVERReceived <br /> Destruction inspection By Dau; Constructed Neil Depth ft <br /> COMMENTS <br /> PE SC Codes IRta ReceivedL- H Datae AmoW Permit/BIL- <br /> ermit/ n IRvoleeR WON mw <br /> 3 ) Oso *77 51f <br /> EM 43-M-M WEB Pe nu.a0 Jabtst r..Ja <br /> 9:11.2007 <br />