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, CLSP-2, CLSP-4 ..__. . - _.. -- -.-.... . —Ndy, � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEA*-RTME, .NT 304E WEBER AVEP•FL- <br /> .. TON CA 95202 -(209)468-3420 <br /> NON-REFUNOABLPPao-" CALL(209)%3-7697 MR INSPECTIONS EXPIRES t Pd <br /> m rr m <br /> JogADDpPsg /_S`5f1/-S. /i�AAIT/!Ey cm21r_- 2.2 7 <br /> /(J _a/(i�05 - rpjS PAST - ws79Td cC $ jj <br /> fpQEg STREET 9�- � ANG EIEE •r/--'�w...i— In <br /> !ZV1 C. z L� !; f"'• <br /> OWNERNA6rc / C CO n-Y�NE IT Z � e <br /> WNER ADDRESS W CITYISTATTIZIP /� W I' 1 <br /> ON <br /> ONE <br /> CONTRACTOR ADDRESS • O /� CI /SI'ATF/GP. a.v II <br /> CCONTRACTOR RV,ONTRA /, +•`�— =. 'D C)J Y.. <br /> ��/h �✓ .. y /� r <br /> SUDCONTRACT00. T/r`e N.l�/.� FIRMS <br /> // 6V?3'f Asn=[ ' CFrr/STATVZIP <br /> SURCONTMCTOR ADDRESS /a/Vyyam�t <br /> j LrcgnSE c-sT 0C4 0o-09 ❑cher NUMBER' EXr1RA1 It V DATe_ 30 � <br /> CEOGRAPHICALINPORMATION: Ca RIMUNala X Lrt AfiIYlJJ�� lif4J9 Towmhip� Raagc^ Snlbn <br /> INTENDEDUSZ s, mneaie/Paivae_ ❑brigadoeJAVicullunl ❑Iodmnal, ❑Wamr Qudily MOnimring DSod Sampling/G'nennerinlion <br /> ❑Public waver 5yya44•ari�lyaFl15't-IXPQ,-M�w3utsmea-nuw Pte, �Rw . r a <br /> IfdiRentunw, vrw' I \q <br /> TYPEOFWORR 11 New Well ❑Re,iaamcm Wcll ❑Well AIMralion/MOdifionkm CI Tell HOU` ❑Un" <br /> auAv err twos �i <br /> XMOmrine Well(a). mere.orraiN �-1pSoil Bning(a)_ r.~artmrss ❑flerum ial Ti <br /> Oi <br /> AHI. Mp9� <br /> O.Well DauRdipn ❑H01-0Fstr ko Well 0Om-0f--Swice Well Rinewal <br /> O New Pump ❑Pump RoplItcennot O Pum Reenti, ❑Cmsa-Connection Repail <br /> WFAJ.CONSTRVMON r� <br /> Drilling Mabod O Mud Robry O Air Roury Auger O Cable Tool ❑Push Point 0 Otho <br /> Propmul Well Depth_ R Ea.,u:0R mdiamemr OOpen BMlOm rTave1P /Gravel Sittf_in dEmeuu t <br /> Ocorduam Cmm, indlaman / Condumor Casing Depth '11 <br /> Well Casing Diameter 2--m TkiclmmsAOougdASTMSchcd!__ F]Slam APIn6c ❑SlaiOleu al [3 Other <br /> Cmul Seal �Drepth L7-3'11 Neal C.1 04 A hug/5-109,11 wale.) ❑SERI Cemm�l 4.k Mla/7 pl waln <br /> pa <br /> 3.,e . Balmdm OO'Asolide) O Manunetmer Spec Y.solids_% Name_ OSpmenpile ❑Spon Submind <br /> Oroul Placenanl Malhod O Pumped Fre FeR D Other O Roardml/Aaeksa a,(name) <br /> PEDESTAL Inslilletl Br AD iller ❑Pump Canuacmr ❑Other <br /> N emuc.te Peduetl Wme..I m:: Width n Ialglh R Thick in c1clooslyBox jvst.wepiN <br /> PUMP Cl Submersible Cl Turbine ❑Dlher Hp_ Pump Set_n SinalingWaklLmd.0 <br /> WE"DETTRULTION D Open Broom 00.1 Pack Cl Umu d ther <br /> Well Diameter in Total Depth II Depth To Water R ❑Cuing In be PerfO amd foren`It an <br /> SnlinE Mataaal ❑Nal Cement f91lh 6+,g/S-10gal wOTer) ❑SUmd Cemml_ aNAmu/2 gal wan 13Bumnim Pellets <br /> ❑Elementm(20%solids) ❑Manufan .Sp.%,oIids__% Name OSpeegonFil, ❑Spee Submilled <br /> PI" ..I Meshed ❑Pumped ❑Free Fall, Cl Other <br /> ❑Compkle with Mumoxam Cap Rbelo.grade ❑Cahplemmfaisdng S fact Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DON IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS, I ALSO CERTIFY TH{{{...T MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AIN IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECFIONS <br /> .;esPATI .BP�wN rro G�a.ot,sre�,uaDAl�'/-i3-2eb3 <br /> SIGNED TYLE - - <br /> ? M M <br /> /-21 191720 <br /> w� <br /> cu <br /> _ LU �- <br /> z ) W - w <br /> _ I <br /> EYAIrI TENT UeV PLY <br /> Applieaion Aeaepl / Daie��/ �+3 Area 1 F.WI.MIDN S3 (a <br /> Grow rupeeB DeT /GILT C V ❑ SPE IAL VVeII Pts 011t <br /> Pumpinspec6c.By - Dam ❑ WAIVER ROGtived <br /> Demnmtion Insp-0.By Dem Conatrudl Well Depth n <br /> Comm E <br /> v <br /> 15 <br /> gltg <br /> Amount Be ev Date PermlU - In Img Well IDN <br /> Remitretl ahs <br /> By Servim ne YatB <br /> ASO ! aa32 4 1 <br /> T� <br /> 1 kEHD4702A0E— MASTER WATER WELL PERMIT <br /> 6TNk002 <br />