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WELLIPUMP PERMIT <br /> SAN JOVCUIN 15�Nlry EwROMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCItXON CA 96202�(209)4W3420 <br /> NON-REFUNDABLE PERMIT 20��1953-7697 FOR INSPECTION$ EXPIRES I YEAR FROM DATE ISSUED <br /> L <br /> AnDREars 't"� <br /> NO <br /> JMA <br /> clucela STREET -2 PARCEL SIZE' �7LAND bell APPUcATIoN 9 <br /> APN tfn <br /> RNAil —ZL'�L– Al, 'j PHONE <br /> It ADERSESS CITYISTATeMP <br /> RACVCA —�'7'-A41- 104`11� 17 �Lid�� PHONE <br /> CONITRACTORADDREn CITYISTATEMP Cie 5-j <br /> SUBCONTRACTOR PHDRE <br /> ,Sumo��cyonAMRE" CITYISTATFJZIP_ <br /> tu ENSE C-57 /"I D-� 0!", NIAMER FDONRATION DATE <br /> GEWRAPHICALINFORMATION: CC,0rV1IgSt0SX_ Y__ Toeirnehip— Fbarl Saactlon— <br /> Dggbreal�rlwfft XI(bgRbon1AgfleUIfijrSI , Industrial Water Quarty Monitoring suit <br /> Public water systern <br /> loh,S'win' <br /> —---------------------- <br /> TYPEOrWeift Near Well Replacement We# Well AllentitionNodification Other <br /> Mandating Wallis)—#of wells S.118.nbg(s)_ Ge.tfhr,cau <br /> Out-OLSONive Well Out-Of-Service Well Reneteall Cross-Conneebon Repair <br /> N�Pump P,MpRevsm—ment , Pump Repair Raw Well Casing <br /> Drillinghlelhod MudRolaw, Alf Rotary Aug., Cable Toot Push Point Other <br /> Preteased Well Depth If E�C.ou.n—in diameter Open Bottom Grainel PacluGravel <br /> C.rdu�olcasulg.i.nrbafreter i CranduchorCasng Depth <br /> WellCasing Diargeterin ThiolmessiGaugeASTNISCIned. Steel Plastic Staunlosal Steel Other <br /> GIOUNSINil Dehm_M Neat Cement(94 lb bW5-10 go/uster) $and Cement sReR,hux17 get tihater <br /> Bankmile,(20%solds) <br /> GNOIC1 Pt�m"t MallbRod , Pumped ,Free Fall � Other <br /> PEDESTAL harealled By -Drills, Pump Ccntractor Other <br /> - Concrete Pedestal Dfianni Wdth R Length_ftThick_hr, Christy Box Ston,.PIw— <br /> ............ . ..... <br /> I?QW —)(submal-bw T'a—�'- Other-- HP--ka— Pump <br /> I HEREBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE MTN ALL <br /> WORKERS COi IN LAWS <br /> IMINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> S TITLE DATE <br /> 1�IT <br /> I PF <br /> I <br /> AA Q I <br /> 44 <br /> ARTMENT UrSE, ONLY <br /> Applm a Accepted D)� Data JAy.7-t2f 2- Area_ Emplay.044�/'A, <br /> By Date SPIECALWOII Pel <br /> P "S Data WAIVER Received <br /> SO Bering Inspal By Carribructind Well Depth_ft <br /> y <br /> AV, /I-tw- <br /> PE I SO Recolveel Anne ue', Date P.rmiv trivial"0 <br /> jut <br /> an <br /> th <br /> C I 'I, Ce Request I <br /> ease hft B 4�R S.'t <br /> Mail R'SU.ftw I'Vow <br />