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WELL/PUMP PERMIT <br /> SAX JQWUW CMA-r V ENVIROWENTAL HEALTH Dcv.UI"W'liT 660 E.etsr Wkm STREET-SIOCKTO.%CA 95M-(209)468.3425 <br /> :VON RE M.NDABLE PWNUT .1.y'j/ �7 EXPIRES I YEAR FRom DwTE ISSUED <br /> 308AWRC55 /OD/—O D—!' �4z�-L �7-0 L'�i�� C� JrZ <br /> �'c...aw <br /> CROSS SIRELT /Oa _"--- --- APN JI0) P,%RCEL SIZE • ii <br /> OAIERNASIK �"' �'v//C PRME 6T <br /> OANERADORESS SL/r,.r /�f/(� CnviSr.ATFJZir <br /> CON TRWFOR 7 'vl tr� &1kzL ! tZp <br /> E - <br /> CONIPUCIORADDRES6 & �W,/ 26 CIMSTATEMP /f"EVv2.5 <br /> SuscotsTRACTOR PHONE <br /> SVICONTRACiOR ADDRESS <br /> L1ES11SE 00-37 C-61 0D-o9 Nr►{REA g'�7y ExPrRArInsD.ITE <br /> CEM:AA4HIC.W I;tFDR.AIAriM: COordlition X �— _ TOA'tnblP, R"v StxrIva <br /> h7ezDi O C sE :PritaL fl lsri�tiaO Agticullt¢a1 O iedasttia! O watat�taliy SlOai:raing G Sa l 3araPling.f ba+ack rizatiaD <br /> O Pubtic Water System--_-� <br /> Hdiff�v::a frco:0uvar: rsa Srxcm 4n.: C—Nam.:-n—vo.. <br /> TS'FE OF WORM G New WellRePluet=t Well G Well Alurmion;N odiucrdon a Test Hale G Other <br /> a Monitoring we4s) ❑Soil Bmiq*s)-- ..rto�cp;> 0 GeatucLDi-.I <br /> a Well Destruction <br /> o Rf-.SnW,;v a Qn-Of-Srnic:Well R"vi'al <br /> uaacw• naDKe <br /> G CrasttmnstiOn Euvair <br /> q'ct.CmsTRt:crto� <br /> DrtSieg]It of• •Jl4W R%ry Cl.fir Roary 0 Auger 0 Cable Tao! a Push Paint m Ckhen <br /> Propowd Wdl :Icpth _R Excavation in diamet r O Open Somal o C.,el Park i Gravel Site In diataeter <br /> a Conductor Casing in diameter I Conductor Casing Depth fl <br /> Web Casing Divuetar_in Thickttcss'Gauge.'ASTM Schad_ _ G S:cel a Plastic 0 Staiulecs Stc.A 0 Other <br /> Greut Seal Dtpttt ft O\cat Cement;Yr fa&g.'S-logs}ttuaer a Sand C.xn.-ta we*mtti i 7 gal wesrc <br /> 17 Bua wadtc IN&soijd) a Msnafwur..r Spec".5 solids_°'o xatrc O Spas Dn fiiiz G SpicsSubtained <br /> Grout Plxemeat 4®lhed (3P'-'Ptd 0 Free Fall G tither a Ret.A.rtl;Ace.-{etator(tumej <br /> i Pt:tn s s t lnsraRed IN R r.w1er Contractor 0 Other <br /> El Cimerde Pedestal Dimmfons: Width_,ft Len h_ Thick in D Cbtisty Bax G Star <br /> Pump :tbmerribk 0 turbine ❑Oulu r HP--2— PWW Sa r. Stattuiiag WaterLet'.j R <br /> WLu.Dr srRucrto-% G Open Bottom 0 Gravel Pad 0 Um scd 0 Odor t <br /> Welt Diamew in Tout Depth ti Depth to whir h G Casing to tc Pcrforatd from A to ft 1 <br /> Sealhlg Material a tixat Ceee at!94 J i s 5 ngrd carer/ G Sand 7 gat ower 0 Bentonite Pallets <br /> 0 Betttanite E?tt:u solids) C7 Mantlfuinrer Spic�•a solids ;, )vame 0 Spas on Fri: a S,-t,^es Sab!tatt� <br /> F12EV"Irnt%Iethnd Q Pumped a I me Fall G Other-- <br /> L0 COmPIOt o ith Mushtwm Coo _ft below Vm& G Complete to Existing Surface Pad <br /> ! IJEREBV CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK VML BE DONE Lv ACCORDANCE WITH SILN <br /> JOAQC'IN COUNTY ORDINANCES,S TE L1RS.AND RULES AND REGULATIONS. I ALSO CERTIFY THAT ITY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV N L A CONTRACTORS STATE LICENSE BOARD AND THAT I ANI M COMPLLUNC£WffH ALL <br /> VIORXERS <br /> /�-D.. O /T <br /> /2O <br /> 1 <br /> t <br /> qY <br /> cF FNr <br /> SFO <br /> 1 1 y ?420 <br /> UlN <br /> pgRT°�Nn' <br /> MENT <br /> J/ DEPARTME?T V4E O� C j <br /> APDiirttmn Aged B, 1� Duue � b arra 1.jq y Empioyte I,F-- <br /> Gr ut 1aswvior By Date ff �t 0 SPECIAL W eII Permit <br /> P=PlftPcctionB* L f ie.:nl�r�,,, � ,hi_-- i7atz '\l"1�14�J 17 WAIL'ERRecelved <br /> Destruction Inspection By _ Via!„, Constructed NV III Depth _ft <br /> COMMENTS <br /> PE SC It..h d 1 .lmoau! to Perttlir! IRvNee# WA 11141 <br /> Codes Info Resettled # <br /> 3 o0 37 1 ' LIL'�1i_ L i <br /> EHD 43-07-M6 WTH ---- R'eS Persil and De6arai2n do: <br />