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13v <br />s � <br />WEL UPUMP PERMIT �> <br />3m.dlomm Comm Ett►+fltamwrALHuLTHDtPAltmemr INS EAUHAMTONAVEVA-STOcxroNCA95=5 - (2W46&U20 <br />N-KEFUNDABLE PERMIT UAt..l <br />AWRees 1 IV. raC <br />asSTREtr_� Gtr APN <br />IER NAME C I% <br />IER ADDRESS •S •� U Tr,, <br />( y <br />TRACTOR K lelm T 4,hx AJ <br />TRACTOR ADDREsa yl Yt <br />CORTRACTOR Mk& t _ar G <br />CONTRACTOR ADOREsa 95`f A Le <br />NsE 4 CS1 O G81 0 D -W 0 Otha <br />-r `JbJ-f OY/ FOR IMPEt:TIQ45 CAt'IKC.1 T TEAR FRUM GATE ISSUED <br />rA_. wzip Tracy 9S30It <br />r PARCEtl t.AMO Ltae APft=TM# <br />r l� ( �� PHONE <br />t1TY/.97A1d7J► Tr t -i ( S) G <br />17^01UIiP_1 ttl{' <br />CITWftA=0F, <br />terra ara>ai�a��rao <br />1 <br />hklMetoe �� 9� S I ExPwT+oN oATg J Z II <br />DOMWW WELL SAMPLING: D (4enwW AflrlereMalftm Ba"a (4391) 0 0ihanmochloroprop3ne (4S 4 O ATswft (4393) <br />0 DarueeldPdwle D ImflaEanfApdallurei 0 urJusbiel B Wator Ouatgy MuniWrirp Soil 9emµlnQ.rClreradcrt[aGar <br />O Public Wistar Sptem <br />It -- t kn Owaar. "I (fecal Contact Nam or Phase t*w&w <br />TtMOPWtonlc 0 NSW Wt! 0 Replecenwril With O Well Altaralton/Modifioation 0 Other <br />0 Monitoring Wog(s) C of wails O Sol Boring(s) a aaa,hldr + (GaotedTllcal a ai twrlada <br />O Oui-OFSelblaa Wdl 0 Oul-Ot-Sorvlce IM h ReneNal 0 Cross-Carwectien Repn1T <br />it Now Pump 0 Puny Re iacwTmi U Pum R*psk B RW&oWe{I CaWiv <br />W LCONS, Ruc-nnN 9 [ <br />nrllting Method 0 MW 0 Air Rotary 0 Auger Oble CaTool PwN Point 0 Otlter <br />Prolxlsad Well Dspihit tomaysldn In disowhr D Open Borism 0 4alAll PaldelOraaal Stre in dlatrlekt <br />D Conrluma Casiltg M dfanMlsr ( Conduclpr Csstng 0spth s <br />Wail Casing Marmnar— In 1WcImessGwupdASTM3dwd 0 Sled O Pleaft O SWNas Steal 0 011 <br />OroutEeal Dep11__S -j Filed Camw*(04lbbaog-10gal we" E! Send asukm6a79slwewr <br />0 Bantonde (40Y1 acids) 0 O'Mr <br />Qruul lacamantMothcd Pumpad 0 N. F.Q 0 Omer ._ 0 Retan4ent/Ac.9.zfor(name) <br />Inetalled By 0 Drlder 0 Pump Cowacior 0 Oihar <br />O Cbncrato Podestat ODimanstnns: Wido R Length f1Thfctt m 0 Chrtaty Box 0 fors Pips <br />Iftmae 0 Submarai s a0 Turbine 0 Other HP Ptdm Set A SMnding Water Levet !t <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED IM APPIJCATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY INANCPS, STATE LAWS, AND RULES AND REOUL ATION9. 1 ALSO CERTIFY THAT VY REQUIRED LICENSE IS <br />CURRENT AND A WTN THE CAUFORNIA CONVRACTORS STATE LJCEME BOARD AND THAT 1 AM IN COMPUANCE WTH ALL <br />WORKERS COMPENSA NLA <br />MINIMUM 49 U %4 O E REQUIRED FOR$?EjN CT1C,�MS - PLEASE CALL (249) 953-7p97� <br />91u ma TITLE MA-% an �— ° DATE f <br />12018 <br />Poylvrr <br />1VrAf <br />�R7MENT UBE ONLY <br />AppMtallon AeCaplad By �' ���'t% C/ 5 tf �' J ATU �I L amloy"11 I') roe d <br />G -d kWp"- By Date 0 SPECLAL Well P4Wmlt <br />Pump 11"20" By Date 0 WArom ReGNed <br />ad eaYtg btspeadw By /le-- Dde ti�i 1 I / � Cernlruabod Well DqM rt <br />OOMME S <br />PE Sc Received <br />Codas biro 8 <br />ChaelW AmountDeb <br />Cash Ramhtad I <br />WTrTIi� Invoksf WaU10N <br />Service Re uast <br />T S <br />AA <br />PBC c01139 <br />ow" W&W UWN WBLaaaf ~r <br />