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ELUPUMP PERMIT <br /> 3 <br /> WIN COUHT`{ IVIRpHhIE TRI NE��}H ONMENTALHEALTH EPART T 1868FASTHAZELT()NAvENuE-STocooNCA95205-6232(209)4683426 <br /> MIT www_ 0"r lehd EXPIRES i YEAR FROM DATE ISSUED <br /> �h KUM RE, La� �, CCUIS� 102 Cr[yalP C i Ew•v- C'S� 4 <br /> OWN, Q 9526 APN. <br /> — t/ C�� PARGEL SIZELD11�LAHO USE APPLICATION# m <br /> s PHONE <br /> Crn'ISTATE/LP tit w. r-t 5 CA . C\s a� I <br /> t MC+ PHONE <br /> Cox ySt7y '1 s� as V\W ST'_- CrrYlSrATEIZIP C r3 ei35i O-l�Sia <br /> DA�L 1��T TT F1 AO �, wtGGp•N� PHONE (5.30)Ct�O-3138 <br /> SII�ILitt v� <br /> TAODRESS l.ro- GM)SrwrE1T1P C]'R,a�vt.4t cd1_ 9S'Ytt,4 <br /> a+ryi R\0�+,�-�/�tG <br /> ovaT',p�p I V} (} NOMBi R ����7 ExpiRAwRDATE =� ~ <br /> JL�4�l��WL�1 04[4VLL�t'�,,. ������y -61 ll q-05 U P�ttler <br /> (115711 �jyyNER �I'"C TRACTOR k f$t58CONTRACTORICONSt3LTANT <br /> C]General MinerallColrform Bacteria(4391)❑Dibromoch€oropropane(4392)C Arsenic(4393) <br /> Af€'t4�ll{ �}11Z�tr�! { tPr[vafe tri9aiionlAgricultural C Industrial C water Quality Monitoring C Soil Sampl'inglCharacterizalion <br /> [`S( tllrLrffl[p41vgt)[V Ifer System 66rrlact Name or Phoma Numter <br /> Ct11311E !1 7LISYI�L ..}J v Ovine Water System Nams <br /> U Replacement Well U Well AlterationlMDdification u Other Por odnes <br /> l Welt{s) #ofwe€Is N Soil 0f_Ser(s} <br /> orhorrngs 7 Geotechnical <br /> IJItiL �cew aput-O€-Servl�WellRenewal ❑Cross-Connection Repair <br /> 0 Pum Re acement D Pump Repair 7 Raise Weil Casin <br /> _i Air Rotary Li Auger U Cable Toe] J Push Point U Othei <br /> II. Y721 VISA p, It Excavation R Y' in diameter D Open BottOra ee ravel Pack/Gravel Size ' in diameter <br /> 1 }1�GSIRI _S,pr ft <br /> Casing 1 C , in diameter f Conductor Casing Depth <br /> tfi 1LU t ) in ThicknesslGauga/ASTM Scfned u Steel U Plastic U Stainless Steel U Other <br /> it U Neat Cement(94 ib bag15-10 gal water) U Sand Cement sack mix77 gal water <br /> �t xl~413Q <br /> 0%solids) 7 Othe <br /> TI�• -1r <br /> !U I, �umged 'KFt2e Fail I I Dther Retardant 1 Accelerator(name) <br /> tJTH ; 2`l �:i Driller ump Contractor L Other <br /> 'edestal 7Dimensions Width it Length it Thick in C Christy Bax C Stove Pipe <br /> len Turbine HP Pump Set ft Standing Water Levet <br /> Iff MID APP�����,re R <br /> HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> - LACES, STATE LAWS, AND RULES AND REGULATIONS. I At-SO CERTIFY THAT MY REQUIRED LICENSE IS <br /> -------"- -----"_- rR THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> LAWS. <br /> UR AAV QUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 r 7 <br /> TrmE I- tv�..ti DATE <br /> anNT PAID, <br /> X421.35 <br /> a <br /> 3If�+>a�T�Rf H�)T ��UIRED � <br /> CtSTf3�l�COPS' <br /> ,rlR�UIIy <br /> DEPARTMENT USE ONLY t� ( h, � <br /> �0 <br /> Application Accepted By <br /> �� Date !G7 � a � Area I/ C7'-f Employee i6 H�M�NT � ' <br /> Grout Inspection By Date 0 SPECIAL.Well PSTI lit <br /> Pump Inspection By tate Ll WAIVER Received <br /> Soil Boring Inspection By I <br /> [Ate Constructed Well Depth ft <br /> Ga <br /> COMMENTS CXI':}tl7' i•^�fils :'YrGs I� "Znf. ('� •r)es.)f�' 4i:7C+f 1f1� ra�i:cv(1U(�e - <br /> PE SC Received Check#! Amount pate PermtN Invoice# Well ID# <br /> Codes Info +Cash Remitted Service Rema- t <br /> ♦./�I L - i'1 l V l,�V ✓ — WEELfP€11NP PFf:Mn <br /> EF9]434)esli v2079 <br />