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I WELL/PUMP PERMIT zl; i E c . i Z <br /> SMI J"QWN CXWRrTV ENVIRONMENTAL HEALTII DEPAIRMEM IMEWLbERAVES"17L-SIOL-RTONCAPSB)2-(209)468-3120 <br /> NON-REFUNDABLE PERMITCALL 209 9517697 FOR I�'APecnons EXPIRES IYEAR FROM DATE ISSUED <br /> YZ_ <br /> Jo%ADDREEY W I+t NJtiL CRYZP •�J-7' <br /> CTOM STR _EET p M APN a'S•3--2I� -2S • PARMSM 31 at P <br /> OWNER MAme <br /> Ic AAIJd A/ s Native .779-- 32 7.1 <br /> OW!cAADDRcsY Cryvlsu VP <br /> CR ILOJ4 <br /> COMRARORADAe66 (/,arg jIX )- <br /> C.IS TVLI <br /> SUfi(OMM(TOA PNONfi <br /> SIICCONTMCIORADDRLIS G}I'Y/$"IATF/2!1P <br /> LICfi1OE OC-57 ❑C6 ❑ <br /> 1 D49 7 <br /> J NMMKR y d EE T10N DATE <br /> GTAICRAPHICALIMPOPMwnO.V: Cwrdlnele X Y Tawehlp RAAge_ Seeuoa <br /> IMEND un .00omodc/Priy�k O llriPdeNApicuhlml ❑Induwial ❑WalloaRrymmhoring O Son Sampling".—ftriaadon <br /> ar own arc —T�Ra— <br /> TMOPWORK ONew Well ❑RryI.t Well O Well AlkntioNModifitadon C3 Test Hole ❑Clber <br /> ❑MwRoring WdUa)_ meewofwdh ❑Sail Boring(.)_ esEm oft—, ❑Cxnaohnial m rof5aw <br /> ❑Well Dauunion ❑Out-OFSmiceWell ❑OutofSmia Well Renew21 <br /> ONmPmp ❑Pww,A aGRenl Repent O Cloa{mnatim Repair <br /> WELL g Metheal 0 <br /> Detlllllg MethoO ❑Mud Roury O Nr Ram ❑Roger ❑Gbk Tool O Push Pain. ❑(Rhee <br /> Propoad Well Deph R Excavatio in diameter ❑Open Beuom ❑Cove Pack/Gravel Sim in diameter <br /> ❑CudmlorCadrlg indianner / Cw;hwwrCasing Deptb It <br /> Well Coslaw Dialmm_in Thickews&XkurdASTM Schd ❑Sal ❑Pude OSDinlas Steel ❑Other__ <br /> Croat Sed Depthfi O Nmt Cement(Y4 lb LegrJ-10gol wart ❑Sid Cement suck.h/7 gal.wr <br /> ❑Brawnite(20%aolid,) ❑M.nufict..Sp¢%solks % Name ❑Spwon FBe OSpm Submiued N <br /> Cwour Plaeeaamt Method OPmopd OFrm Fall ❑(Ther. OReuMM/Aaektata(name) <br /> PEbMAL lemlld By E3 Driller OPump C.mraekr ❑(Ther <br /> Cl Concrete Pedestal DlnanMsm: Width R Len mR Thkk in ❑Christy Bos OSwve Plpe <br /> POMP ubrrenbk OTulbim 0Other HP a Pump Set `BO A Sordi.,Watcr(eel It r <br /> Weu Dmnu DN ❑Open Bak. ❑Onvd Pak ❑Unuaal ❑Otho <br /> Well l)wmela in Tool Dcptb ft D n m W.xr N ❑Cuing nt h Pafonsd rrom_A m_M1 Z <br /> Saliag Makrid ❑Nal Crown,M lb bot,1540g.4 y ) ❑Sand Covent x kark f 7 gal want ❑Bemmmine Pelku m <br /> ❑Bmlmile(20%solids) ❑Maoufwtumr Spm%eolidr__% Name OSpecanFe ❑Spas Sobndnd <br /> Plaement Method O Pumped ❑Fre Fall O Other <br /> ❑Campk w with Mud..Can ft below grade O Complete m Existing Sunset Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONT; 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 STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> "BEERS COMPENS 1 LAWS _, <br /> MINIMUM 24 HOUR ADVANCE NOTIaCE�,REQ TIRED FOR INSPECTIONS <br /> SITaIEp Tlnx DATE <br /> g <br /> �/� DEPARTDow 1 IVY IL�S•(o S <br /> Application Accepted By. d1CY�- Dow 0 e Ara u 6 Em,-,lore log <br /> Great Impmum By Daa ❑ SPECIAL Well Permit <br /> pump lnspmtm By Date 0 WAIVER Receive <br /> Da,mwelioa lospee B)) Date Caoslry�+d Well laepth A <br /> COMMENTS /�//9/wT �>f ,d �.a ,! /-p r a.✓,�� /)+.I:-" L�--'(� ' <br /> CPedes la( Rammed Aegcel7d Dale garviaR uavY 1 imY Well ID/ <br /> yet. oxo .So n lI 1cj grie 4, 1 k1p .39 -M <br /> J <br /> $X047-02-006 MASTER W AT®WEIL PERMIT <br />