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/ WELL/PUMP PERMIT <br /> � � <br /> r r 1 <br /> BAN JOAQUIN COLPiYY ELy1RONMTMALNllg,,,,T11 DVAn"HE <br /> NON-REFUNDABLE PERMIT CALL(209)953.7697 FOR INSPECTIONS WEBER AVE <br /> EXPIRES <br /> STaYEAR FR 95DATE ISSUED 42p <br /> �U �Ju.sT.E'XPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREBS /l0O/ Al. BIAD JSEL/.-r/ �> S( 'I a- 17' <br /> .a-V.D�� �L11 Cm/LP 71jC/L7z j <br /> CROSe STReLT jl)A I APN fbI-.2 J-PO'l "—D/0/-,s-1JD-"3 g <br /> / PARCELSIZE- - LAND USE APPLIGTp <br /> O"ER NAME 2/=y c97Z^j r �(- f PHONE <br /> OWnER ADBRLA4 '3 r//� GT�� '�EriAf`.({//'L-� 5T- Cm/gTwTGZ1Y STbCIC'J)TpN, C�/A�/�/�S.ZGS- <br /> GDerrMtTOR PE i_t(/Vr LeJt�rle eve-, PHONE <br /> CONERACEOR ADDRESS MVR7Zl ST CmISTATMIP <br /> gUBEDM'WCrOR <br /> PNONE <br /> SUBCOMMCIOp AD�DREI9 CFEV S AT IIP <br /> LICENIiE PC-57 DC-DI 13 D-09 OOlher NUMBER / �- EXPIMTIONDATE U <br /> GEDGMPHtC.AL INPDRMATION: Ceardimens, X V Townshli, Range_ Section_ <br /> INEENDeo UBE ❑DomatidPnvata ❑Iniguion/Agneulmlal ❑Indwlnal O Water Quality Monironeg s ImgA]nracmdatlon <br /> 13 Public Water s em <br /> NGRNmI rrom ON., r rNnn ne lice <br /> TTPE OF WORN, ❑New Well O Replacement Well O Well Al4urio VNIce ifiution ❑Tat Hole ��D Other <br /> ❑Monimnng Wdl(s)_Mofwells 13 5o41 Bonog(a) a°rhon.Me z;,r75 chniul ..(1xm . <br /> ❑Well Destruction ❑Out-Of-Seviw Well ❑OW"-Serviw Wall R.) <br /> ❑New Pon O Pum R la., O P R air ❑CroasConnalion 0. <br /> WETJ.CquBERtlrnon - � it <br /> "ling Michael 13 Mud Raary ❑Air Rotary �A�R�estt O CableTool 13 Push Puinl [3 Other <br /> Prop.w West Dell,s-ate R PYcanetion Y.�. in diuncor OOpen Bottom EJ.. Peck/Gravel Sim in diamacr C, <br /> ❑Colducmr G:ng sin diamearr I ComdU oRCasing DepN R <br /> Well Casing Diamcur_in Thieknen/GaugdASTM Scheel O Skel ❑Phmic ❑Suimen Steel ❑Other <br /> Grout Sul Depen R ❑Neal Cement(94 th hog/5-/0 gal waver) ❑Sand Cement sack Mtx/7 gal We it. <br /> ❑Bemonik(20H wlide) ❑Manu(twee Spec h solids_M Name O Specs on Fik O Specs submitted IT <br /> Goat Placement Method 0hooped ❑Free Fall C Other ❑Retardant/Accelerator(Dora) rC <br /> PeDEDrAL Installed By O Dnller ❑Pump Contractor OOther O <br /> ❑Concrete Pedestal Dlmeaalos: Width _ft Length ft Thick in OChrlYy Boa 13Sh.0 Pips <br /> POeer ❑Submersible ❑Turbine ElOther HP_ Pumpset_ft Svndiog Wutt Level ft r <br /> WELL DEBTRUCTION ❑Gotta not. ❑Gnwl Pack O U.w OOMtt <br /> Wellgamccr in Tntal DgNh R Depthln Wawa fl OCamegmbe Perfore�tad�6om flto S (1 ! <br /> Seapng Material O Nut Cement(94/h bog/5-10ga/warn) O S-A C--1 .sack ma 17 gal wake ut�EB ones Pcllas �s <br /> O Bentonite(20%solids) O ManRfmtamr Spec%spuds % Name O Spas on Fik O Specs Sub mi <br /> Placamem Method ❑NurpN O Fra Fall OOther <br /> O Com lien with Mushroom Cap fl below gmdc O Complete m exacell,Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQWN COUNTY ORDINANCES,STATE LAWS, D RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT A ACTIVE WIT k IB C RN ONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS PENSATION <br /> N 1 M 24 F R ADVANCE NOTICE <br /> }REQUIRED FOR INSPECTIONS �J <br /> SIGNED / Tim EE�IIDATE I b <br /> 411,-,4- . . •p <br /> t 41, NMA.. I SAN,. <br /> ... <br /> / /� DEPARTMENT USEIONY <br /> Application Amepand By 440 Dale 4+1-710t4 Art. Zf/ Empwyalm S9`s"f <br /> Grout Ioapactlon By Dale ❑ SPECIAU Well PeEmlt / <br /> Pump lnapmdon By Due ❑ WAIVER Resolved <br /> -BertmYen Inspection By Dam e7�-�-�� Constructed Wall Depth R <br /> COMMENTS �i t � WAAkS lK''7?A )! -/ gcrfrtr_[�✓c�d�Y Ciinl�c T�/c id rr+%_�� <br /> /.LASS'.2J���f4i e=a�fY-F ./c."L •FJlafi7/�J/iv�"�!sE'3L�Ge(io .�iA/�in -Fx <br /> PE SC Ratlred pecldN AmpuDt Permit/ <br /> Coda 1.16B Be Remllta0 Mk SmkeR lints InwkeM Wall IM <br /> CND6e3-M6 Mr2TFA WATER WFJIPFAMR <br /> IJI}]IIMJ <br />