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vel-) <br />ev-ne <br />—A-1 <br />WELLIPUMP PERMIT <br />SAN Jamna COIMTY ENVROIINBITAL Hmm DeAMW 130 Easy HAZELTON Avow-STOOMM CA 8232 (IU9) 46&3420 <br />NON-REFu►wASLE PeRrar www-skW <br />vyo4ehd EXPUZES 1 YEAR MGM DATE ISSUED <br />JOa ftowss A29 7 U.•' i I <br />Q4, -A!5 / f �-, C� c:tiTrm/� �� CA I D n q5'320 <br />m <br />CROSS S. Sex 1-Jl� A"0 y 7 J �0i � PARcs_s— 'JJ—_L—u-AW--# g <br />OWNERNME W4,1 +e r,�v(� P. <br />OWNMADDRESS S�• h^(' ,� 1 7YISiATFil� ESG�ii D/'1 cf S 3 Z O <br />ContwlcroaAoowm 1, i <br />SURCOWTRACTIORICCUSIXTAI" <br />PROW <br />(YrrlSrwrHLP� <br />PHpf <br />SUBCONTRACTORICONAD-Toff ADORES C7rYMrATETLP <br />Lv:"se ❑ C-57 XG l C D -M ❑ O#W [�r�t�O j Y1� E.F.1 DMDATE �— <br />EWUMG PARTY: -1 OWNER V15.RwcroR ❑ S18[�IrnACiORICoN51717awr <br />110—wnc Wai S..- U cxneral MinerailColiform Bacteria (4391) u (4332) U ArSertiG (43393) <br />Ij�EhmlC� U OrtteStidPTivdjle 7 trriugatiardAgriarlltaal L Ind 0 Water Quality Mar>ftamg n Sol Samplffr4tc wracertzation <br />n Pubficwater Syslen, _ <br />n ddwS t om 0—.. waw uyswe Mw—CaM Nr a Prow Munbm <br />T ym OF VAmm 1 I New Well I I Reptant Well i Well MievalimfModdcation I Other <br />I I Monitoring We3(s) # of weds I Soil Borh4s) 4 or bOrwo I Geotechnical a of bong' <br />I I Out-0f-ServiceWelll I 10UI-0f-SPIbiCO W.M Pmnew 4 1 I Cross -Connection Rep - <br />1 I Near Pune ;R;; Redxsnerd I I Pump Revair 1 I Raise Well Casvi9 <br />Drilling Method I I Mud Rotary I Aa Rotary t Auger I I Cade Tool I I Push Pant I I Other <br />Proposed Web Depth It Excavator it thaneter J Open Botwn CI G-raYcIPaWGMM 81ze m d;am0er <br />❑ Calducbx Casmg tndiameter i Canduclor Casing Depth ft <br />Web Casing Diameter _ in TledareWGaugdASTM Shed 7 Stem ❑ Plasthc n Staiiess Sted L Other <br />Grout Seal Depth ft n Neat Cement (94 lb b0905-10 gat wafer) n $amend Cement saim mu" gal water <br />I1 Bcnwnde(20%SOLOS) 1 other _ <br />GrwrtPtacement Ydhnd L! Pumped ❑ Free Fab -] Other � Retamdantl Accelerata(name) <br />Pt RAL belA d By 0 Driller ❑ Ptmtp Contradrx u Oder ar C <br />11 Concm a Pedestal t Di nm6*w Wid3t ft Length R Thick in 1 1 Christy Boz I Stove Pte <br />hrrrersTbleC Tlahme G Other HP PumpSW__Lg_3 ft Starh3rg Wader Level ft <br />I MRI <br />HEREBY CERTIFY THAT 1 HAVE PREPARED TS APPLICATION AND THAT THE WORK WILL BE DONE ACCORDANCE WITH SAN <br />JOAOUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT NY RKH W" LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM NN COMPLIANCE WRH ALL <br />WORIUSRS COMPENSATION LAWS_ <br />INIUM ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />S15i�D l �fl.� ren Eilx! }/hct O L DATE 7' Z ' Z c 2-1 <br />,/DEPARTMENT USE ONLY q % <br />Application Accepted BY �`� Date Area �(! Employee ID# 1. <br />Grout Inspection By Date O SPECIAL WeN Permit <br />P—P tnspart— By o WAIVER. Received <br />Sal BOfing IrMPRC mon By Date Constructed Well Depth ft <br />COMMENTS <br />�M-1 -Am 10—.7 - <br />FimO aloe EIImIy11A <br />o- ---A lz� 7, �Xz'F� (/ <br />?E11G10 <br />yMFN <br />C`c�VF� <br />4 QU/N <br />DFP 11 Y <br />NT <br />VYWELL AIUW PEcaAet <br />