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WELL/PUMP PERMIT <br /> SAN JOAQUIN CrJUNTY ENVIROMAEWAL HEALTH DEPARTMENT 304E Ween Ave 3-F1-SrowroN CA 95m2-(219)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JQ.AQRI� 5�18Y— Nwy /� /xK 1 �12 C.11, Jxar c avv <br /> CROBS SIReeT_ n/('�I' /� AIPNCO���/JO�V1�C `�^�PAReeLWu _LANG U9EAP�PIu�cAnnon pl�Ys A <br /> Oaam NAME �K^N� e+r� ✓rC/J�✓L1P(Li J1Y� PHONE O/ 9a� <br /> OWNER AIHHtrss 2l o �kl CrL wev /� C1TTrsTAWZ.P �t l-A. 2S:2/ 2 <br /> CQMPACTQR PHONE <br /> CONTRACTOR AOUREN CrrvJsrATV/JP <br /> SUncOwRA(TOR Palmer <br /> SUR[ONTRACfOR AmCHTMATPJ/JP <br /> LICENSE ❑C-57 0C41 DD49 OOther NUMBER_ ExnRAnon DATE <br /> GFAORAPHICAL INPOMIAnON: CaardlYtea % Y TOWneWF_ Range_ geeHell <br /> i noR a ❑Wnlntic/Priwte ❑Irriptioe/AgricWWnl Cl Industrial O Water Qulity Monitoring ❑Soil SsmplinglChslacteriaHon <br /> 0 Public Water Sntrni <br /> H4iNmaR Mm Owns e.. ^°u'r e"'°r <br /> TYPE OF Wonrc 0 New Well O Replacement Well ❑Well AlreretioNModifieation ❑other <br /> ❑Monitoring Well(s)_M of a,el is o S d B ming(.) ""E' O Gatahnicd .or.wia® <br /> )III[Det-0f-Service Well OOut-Of-Sema Well Renewal ❑Cress-Connecticn Repair <br /> 0 New Patent, O Pum Repacennent 0 Ptintp R it <br /> wen CONRfaUCTON <br /> DdWq Metkod 0Mee Reury (3 Ail ll 0Auger OCabk Tool Cl Push Point OOWer M <br /> PlepaMd Well DspN ft Eauv.licn in diameter 0 Open Stole 0 Gravel Pack/Gravd Si. in diameter `�V <br /> 0 Conductor GHng in diameter / Conductor Cutng Depth ft <br /> Well Cadeg Diameter_ n Thick DHEADauedASTM Schad Cl Steel 0 Plattic ❑Stainless Sred 0 Otha <br /> Grow Snl Depth r ft Cl Neat Cement(94 ID Dag/5-/0 ger/amrr) OSOW Cemat sack mir/7gal water <br /> 0 B,mamite(2VA solids) 0Mwufaaura Spec%winds % Name 13 Specs on It 0Spas Submined <br /> Grout Plueeaet Medled 0 Pumped ❑Fra Fall 0 ONtt 0 Retardant/Acecknaw(name) <br /> PEorsraL md.lkd By 0 Drilla 0 Pump Comactor 0 qhs <br /> 0 Coante Peded.l DlmenWu:Width ft [rngN ft Thick i. 0 CNd goer 0 Stave IN, <br /> P1aR 0 Submersible 0 Turbine 0 fMet HP Pump Sat ftSaMxIm8 Wats l.evd ft <br /> I HEREBY CERTIFY THAT I HAVE 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 STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL ti <br /> WORKERS COMPENSATION LAWS N <br /> �J"MIN M 24 H�00 DVANCE NOTICE R�FQUIRED FOR INSPECTIONS / I <br /> scneo �h!!S A• Tine o%A5 U r <br /> LL <br /> ETIT <br /> -- "- - -- OMDMENT USE ON Y/Appliatme Aeosp7 -/— Area Employee IDp L�IL D.� <br /> Grant Inspection By Dare ❑ SPECIAL WNI Permit / <br /> Pump lnspectiw By Dare ❑ WAIVER Received <br /> Co.atr.etad W <br /> On ft <br /> 7 <br /> COMMEN �-. <br /> PE SC Received coAmount ah PerMU lewim well uv <br /> Cada lefa B �° � Sem Rest <br /> /DD L D Llloq <br /> sm.t EUMe ruutrr <br /> Sxo Oa:ua <br /> imams <br />