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WELL/PUMP PERMIT <br /> SAN IOAQutm COUNTY ENVIRORMENTALHEALTH DEPARTMENT 304EWUSMAVE3`FL-gTDERTONCA95202 -O")46E-N20 <br /> NON-REFUNDABLE PERMIT CALL(204)9537697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> 1f2 <br /> .IORABagEss l `l_� CRhYMP <br /> • CROS STREET ' APN M /SII /� �d�J PARCEL SIM3 7 8),2— <br /> _ <br /> OWNCR NAME '~ PHONE ~ <br /> OWNER ADDRESS I� J CRYISTATPJ7JP <br /> CONtRACTOR 01/ PHONE <br /> CormucroR Awaxas� 7 rh r4 <br /> L t ' C[lYlSTATE2IP <br /> SUPCUNrRAETOR_ PHONE O <br /> BUCONI'RACEOR ADDRIM_ CITV/STATEMP <br /> L,GEER, C-57 fit 0D-09 OOrha NUMBER E...nONDATE v� <br /> pEOGRwPOwLINPpIMATIon: C.ardlmles K lrTownEIIP_ Ra.ge__ Seeder— <br /> ' INTD1DtDUSE Dameetic/Pni Cl IrrigatiedAgriculmnl ❑Irdu.dal O Watt,Quality mcn.mring O Soil S.mpiinN/Cherecmrimdon <br /> D Public WamrS eWn <br /> veitDNet r�mn�Wn .m em ante _T v <br /> TTEOPWom ONew Well O Repleceenea,Weil ❑Well Al,erewo/Modifiewdon ❑Tea Hole ❑Other <br /> O Monitoring Well(.)____ wmbrrafwen, DS.il eonng(c)_ umnevcufh ., 0Gvewthmeel number olbennp <br /> ❑Wcll Ocnmchot DOuI-0f-Smiee Well OOut-Of--Smice Well Renewal <br /> ew Pum D Pu R lerenter, O Purnp R it O C..-Conneoi.Repair <br /> WELLCONATDiN;ITON <br /> Drilling Method ❑Mud Rotary O Air RoNry ❑Aog. ❑Cable Tool O Pueh Ppim O Ober <br /> Pr.pesed WED Depth ft Exca d-1 in diameter 0Open Boonton ❑Grew]Pock I Gond Sia in dmxmmt <br /> ❑C.tducmr Casing i.diam:kr / Conduct.Casing Depth _ft <br /> Well Casing Diemener_in Thkkrm GaugrIASTM Sthd ❑Steel O PMe,ic ❑Steelton;Send DOtho <br /> G.1 Sed Dcph ft O Nal Center,IN lb bog/3-10 gal Narrr) 0Send Cemem .r.rA nth/7 gal we>Q <br /> ❑Benmpite(20%solid.) ❑M...&.Wm Sp.%wgda_% Nemec ❑Spvc on File ❑Spas SubmlNd <br /> Grout PlaceaeatMalad ❑Pumped OFree Fail C3 Other DRevrtnol/Accclmar(name) <br /> PEHUITAL Isaalleda ❑Drilla Pl Pump Con:racwr 00th. <br /> ownee,Pedestal Dinee.ba: Widths ft lrngrh A Thick in ❑Chrlry Boa ❑Stove Pipe <br /> PUMP WSubmereible 0Turbine ❑Other__ HP.,;L_ pump Set ft Standing Water level //re R <br /> WELL DMTRULTION ❑Open Serrano DGHvel Peck DUneEei ❑Other <br /> well DlEmner_in Total Depth ft Depth m Water R D Casing no be Perforercli Rom_ft no_R <br /> • Se"rit Material ❑Nnl Cement 94 lb lag/1-l0 g.lwan) OSend.,nrNn, ruck mi./7 gel w.wr ❑Beemni.Pelku <br /> O Bemmnite 2O%solid.) OMmufecmar Spec%solids % Name OSI--Mk Dlpaa Submind <br /> PIw,,.w Metal D Pumped ❑Fra Fall ❑Other-- <br /> CI Comptes With Mu.bmart cap A beloW mde__ ❑Complete to Existing Surfax Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND TWIT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 30AQUIN 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 <br /> WORKERS COMPENSATION LAWS. <br /> _ _ U HOUR NCE ICE REQUIREDF SPECTIONS-PLEASE CALL(209)953-7 7 <br /> &GRED _� TIT{L DATE <br /> N <br /> ',lL <br /> E <br /> DEPARTMENT USE ONLY j <br /> Applicefion Aaepted By D.he f —/-1 02 A. l/ Ewloyec IDg <br /> Gmut InryaRan By Dete ❑ SPECIAL Wdl Perrdt <br /> Pump lnspation Emc �—OQQ—O.� 13WAIVERRecelYed <br /> Deswcrion Inspeoti.n BY Date CeR.ltdeted WNI Depth ft <br /> COMMENT! <br /> • PE SC Realved a AmountDA[e Perm1U IawieeN Weil lb <br /> Ceder lar. aN SteelServlre BerlN <br /> O OSO a3 3 a- ID o3 <br /> RHDA3A2-00E <br /> r, 18[42002 MASTER WATER WELL PERMIT <br /> Y <br /> _ I <br />