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tea- WELL/PUMP PERMIT i <br /> SARJOAQUVR CDINI YENVIBUNMP Al,HEALTH DMARTMBNT 304E WFJER AVE 3m FL-SnXXTON CA 95ME - CM)469-3420 <br /> NON-REFUNDABLE PERMITCALL f2p9)953-7697 POP INSPECTIONS EXPIRES 1 YEAR PROM DATE ISSUED <br /> JOB ADDvra / CDYZP <br /> C:BM Blw APN 'o3 230/3 <br /> O"ER NAMEib� PRONE <br /> ORHERADDHmT S CmISTATE)TAP <br /> no <br /> CONTRACIOB ADORESV X LMh7ATEZP lJlll�1 —I-7Y <br /> SuBcDNrewcroa PHONE 1l� <br /> Stvcct crctR ADDaeee CnY/SrATErLjP v <br /> Lt®eEL C-57 )G C-61 ❑D49 ❑Other NUMBER S 3 EXP1RAnON DATE <br /> G1mOR.vFHt INFORMATION: Courdbu les X Y TowmMp Range_ Se0doo <br /> INTENDED USE Domadc/Priv.e O lrrigetlon/Agiedtual 13Industrial ❑WauQuOity Monitoring M Soil SemPling/Characterinfica <br /> ❑Public W.er Sy{� <br /> waft.,VD.�: nor eve <br /> TYPE OP WORE New Well 13 RepkeeBmt Well ❑Wdl AltmdoNMudi(w.4On 13 TW Hole ❑Other <br /> ❑Mmiaring Weil(s) _ mmN .fr b I3Soil Boring(.)_ eumemerbo,ing ❑Omtahnical mwbmertm6yp \' <br /> •Well Deswwdm ❑Out4)(-SaVwe Well ❑Out—Of—Sawa Well Renewal <br /> New Pum r 13 P=p Replizertt.1 ❑Pump Repair ❑Cron-Cwtwcmu Repir <br /> VA CuN utNv <br /> DrMn MotMdcMud Rotary ❑Air Rotary ❑AuggJ 13 Cablc Tool ❑Push Poi. O Other <br /> Pmpoaed Well Depth .29a R Pacewfion._�_� _ie diameter ❑Open Bottom *XOnvel Peck/(bawlSis indiamdu <br /> ❑Conductor Cwfng iudiBwmr / Coa—d�w-t�Ceci�(8 Depth R. <br /> Well Cauln Diem ur�in nicknem/OeugdASTM Sched ❑Sael )011 k ❑S 'n a S el 13 Oth, <br /> Croat SW Depth G/ n, ft ❑Neer Canepit'94 Ihbg/5-1Ogalwoter/ x5and Cenatt 3i _ k.k17SW wear <br /> ❑Benet 'a(20% fids) ❑MevuRmaer Spec%.olid,_% Name ❑Spa,m File ❑Spm Subadttcd <br /> Croat Phwemovt Mdbod Pumped 13 Free Fell ❑Other_ O Retadant/Aeceleratar(rame) <br /> PmEWrAL Iaealled By -Uu ❑Pwtp Cmvacmr 0O:hW <br /> [3Coocnte Pedwl Dlmemlom: Width ft Lrngdt R Thick t. is D Chrigy Bin D Seine Pipe <br /> PUMP ubmemblc ❑Turbine ❑OthaHPPump�Sett�� R SWegdiWaterlavel ft <br /> WELL DE41'RELTIDN ❑Opts Rotten: vd Pack CIUn..Rd OOdlar <br /> Weil DOmetu_iu TOW Depth ft Depth a Wets R ❑C swX w be Palbmad Rom_R a 6 <br /> SeaBng Material ❑Nen Canmt T94 N Dog/5-/0gv/aaerJ ❑Sand Cement rack mfr/7 gal wear ❑Bmmm Pellets <br /> n Heater,(30%solider) ❑Maoufeeova Spa%soUda % Name O Spm m File 13 Spm SubtNned <br /> Plaeemeut Method ❑Pumped ❑I=Fall 13 Other <br /> ❑Camplde wild Mushaom CAP R below gale_ ❑Complex a afating Surfeee Pad . <br /> I HEREBY CERTIFY THAT 1 RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES.STATE LAWS. AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS SPATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M R AI)VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2 9�3j.76 7 <br /> STONED rt Tas, DATE ?7 <br /> Q - P <br /> Ns <br /> NM M BE DM DM <br /> DEPARTMENT UWPIlLy - <br /> Application Accepted By�- tea 411191B Areae Employee TDR <br /> Gmut Impadco One ❑ SPECIAL W011 PerRtit <br /> Pump Uapcdo _ Deer — d ❑ WAIVERRecelved <br /> Datructico Imp.4.By Dam Coudructed Well Depth _R <br /> COMMENTS <br /> PE SC Received CMe Amoom Date perwhl fuvOlaA Well IDN <br /> fatly K00 BY Re dUccl Srvfea Regum0 <br /> t o 3Sl <br /> o dso 55 <br />