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DATE
<br />25 2020
<br />QA,uhv
<br />ITMN
<br />cr) ,v146- (Jivr
<br />N L r
<br />0.14:
<br />Date
<br />Date.
<br />3 /Rho- v
<br />
<br />Dram Imp:vegan By
<br />
<br />PaLnp Impaction By f‘t., IN L.4 S &Oil OI-M • a_
<br />
<br />Dem-medal inspection By
<br />COMMENTS
<br />0 SPECIAL Well Permit
<br />0 WAIVER Received
<br />Constructed Well Depth
<br />WELL PUMP PERMIT
<br />Saz 30.1QVIN CO VNT lOWLRONMENTALIFEet.le EHDARFNIENT 609E45/MAIN STREET - DititCNION CA 9M02 - (209)468-3420
<br />NON-REFUNDABLE PERMIT EMIRES I YEAR FROM DATE ISSUED
<br />1.00 AUDDESS
<br />CROSS' S-rn ZS c -royie APN oe 3 ?go 0 S' „A„ca, 3, /Li
<br />OWNER NAM ,'f-XED l/4-Z— PifONE 5767 573/
<br /> 9,52 90
<br />5,/vozelif '.5Z
<br />StACONTRACTOR
<br />
<br />PHONE
<br />
<br />Sunceninthcrom ADDRESS
<br />
<br />TACENSE . 0 C-57 SI ID D-09 0 Other Es:AMMON DATE
<br />i MENDED
<br />GEOCAIADDICAL ZA HON: Coordinates X Y
<br />USE LttesgoPrivata 0 InigatiorvAmicultaral D lodostrial 0 Water Quality Monitoring 0 So1 Sarroling Cluract.anizmica 1
<br />I M Public Water System
<br />I
<br />IF dinnna fr.: C.1..., 1,Kezr Sy-an San:. CC=•.2 :V.. 07 MC= VI:,!,:..,
<br /> 1
<br />Ts:sc OF WoRN 0 Nam. Well Axtpaarmnent Weil 0 Well AlieraMmeModiEmnion 0 Test Hold 0 Other
<br />0 Monitoring Wallis) 0 Soil Borinels) r''''''''''f t'd.'t' 0 Crecumluticel
<br />d.,..-:1-.-.,,,
<br />0 Weil Deathscticra 0 Oat-Of-Sarvicc Wall 0 Out-01-Servica Well lionev.-21
<br />ET Sew Ps= ktunn Reolacemem 0 Penno Remit- 0 Casa-Commerim Rthair
<br />Wail. CONSTRI.Crielt
<br />Driffing Method 0 Med Rolm) 0 Air Fctary fai Auga 0 Cable Teo! 0 Pm& POil'U 0 Other
<br />Prop:mail Weil De-pth_______ it Excavation in cEammer 0 Open Bottom 0 Gravel Pack i Gravel Size in diameter I
<br />0 Cm:dam:or Cuing in diameter 1 Conductor Casio, Death ft
<br />I Well Casing Dimmer inThicimes,f-!QenseASTM Setted 0 S:act 0 Plastic 0 Stainless Steel Cl Other
<br />Grout Seal Depth ft 0 Nom Cement :Vd. fn Xac!a-Itlgal ;t1Per) 0 Send L'eamr: fad; tat : ,' 7 gal Water
<br />0 BantfAlla im; sanity 0 Manufauvuror Spee el, solids ''.-:. Nmte 0 Sp:es on File 0 5.,txxs Schmitt:4 i
<br />Gratt Placement Method 0 Pumped 0 Pre,: RID 0 Other 0 R...131-darA : Ace:lomat frcascl i
<br />PEDESTAL IssinHaD Dv 0 Driller Cl Pump Contractor Cl Other
<br />0 Concrete Pedestal Dimensions: Width il Length ft Thick ill
<br />OIP Ihreersibk. 0 Turbine 0 Odin iiP
<br />0 Christy Box Cl Starve Pip
<br />P
<br />I
<br />Pump Sal ..7/110. ft St9nding Wmer Le-ol f it I
<br />/.3.F.YYL e--44x Co‘floP zef, ?5-z 92
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<br />Cox rnAcrom 013L--1-/ a)/9-7-72- //1121<-
<br />CONTRACIOR ADDRLS, 7g6 57/0 y
<br />NuituE S7:3;d2e)
<br />Township Ramp Section_ _
<br />
<br />'WELL DESTRUCHON 0 Opert. a:W.0M r:1 Gra,a1 Pack 0 lan,..7.1 0 Other ,
<br />Wait Diarnatar in 'fetal Dapth il Depth te, Wai.:, _ It Cl Cming to be Pe,-formed from tt to ft
<br />
<br />Senlinq Material 1-.3 Nest CcEEnt .#94 lb S-I n grz 1 Wagrerj 0 Faxd Ettr, -: tack =ft i 7 sal valer 0 BiatnnPz1;a;s ;
<br />0 Evitortite tirtu stliteis) CI :lineufzeturer Spec ''..i, solids ___ 7-;', !,-,..r,c, 0 Spes ea Ffic 0 STees SubefItzl !
<br />
<br />Pideement Method 0 Permed Cl Frei: Fail 0 Other
<br />CI Complete vc hit Mushroom Cop ft below ..1.-17.4.2 0 Complete nti Easing SurfacePad
<br />HEREBY CERTIFY' THAT
<br />1, (h cous-TY 0 L .
<br />CURRENT AND "41,0 17 ad
<br />wavia-n '
<br />010•41"1,14.4,
<br />417411,21i-kE
<br />RE_PARED ims APPLICATION AND THAT THE WORK 1111.3. BE DONE IN ACCORDA.NCE WITH SAN
<br />A LAWS. AND RULES AND REGULATIONS. CERTIFY THAT MY REQUIRED LICENSE IS
<br />'ORNTA CONTRACTORS STATE LICENSE BOARD ANSI THAT AM INCOMPLIANCE WITH ALL
<br />SiGNED
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<br />MIN i --_-__ ._- /
<br />DEPARTMENT UfiE 0N1tY
<br />Applieetion Accepted Date 6PS/a e9
<br />1
<br />Atc qbq E.00et 1E7. -5 k
<br />PE
<br />Codas
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<br />late
<br />Received
<br />Rs_
<br />ITV,' Mooted
<br />Remitted Dote Permit/ -Rice Regatta Invoke # I WrIl IDN
<br />&del 0.70 610-•""... Tem *77 $11 '5.7-0 wroulim 6 i
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<br />9,111E07 Wei Pnnnif and Dethninentles
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