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MAR 213 2003 4:41PM HP LASERJET 3200 P. 1 <br /> -P <br /> WELL/PUMP PERMIT <br /> A SAN JOAQUIN COUNTY ENVIRONMENTAL. TN DEPARTMENT JO4EWeRERAv[3�F•p[RTONCA952p2- <br /> NON-REFUNDABLE PERMIT (2IN)46B-3420 <br /> CALL 209 953.7697 FOR Irvspecrwns EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDpEBB 2042f f/77C=rI�,g{ Q�Opf G�TY/'Z�ar{_}2� ��y g <br /> CROSS STREET p-• 1 APIN G2L--L/010LC SRZ PARCELSIEE� - I .5 <br /> OWNER NAAaE Tror� TiPBP4, S,UL arBGlwW�CLW/h[( CP.lwne\I I��O�1(1- G fest] <br /> Own[a ADDRTse �.A I //100/ /t CITv/STATV2n YlG �/k/.r A�Z <br /> CONTRACTOR Lt-,q;e.T�1�L�S�. ICe�.np/� (yPIIOONNB`���B - 9/Q-r[r00 <br /> CONTRACTOR AWIRP55 -LIOI fYIPM R/yd y'y��a.� CMYSTATMLIP�aRJ 'p l(, <br /> E �{ <br /> $UROONIRACTOR_{pm" <br /> SURCONTRACTORADORCiy�IG /(p7� aCyITpYI/gyTATF/TAy FE,{�/Jp'Zp yy L� f'3 <br /> LICERSR -57 0C41 13D09 0Othas NUMBR0. �O.i! E%PIMTION❑ATC 3� <br /> CCOCRgPNICALINPORMATION: Caerdboo,o X Y Township kange_ Se[Hnn_ (� <br /> IVIENDRO Us[ ODomeadrhdvvc rtignrionsApicubunl <br /> 13 Industrial O Water QURMY Monitoring 11 Suit S,mPI _L• <br /> Cl Public Wata Syy.km P urglGlanckdration �l f <br /> Ifaifhrcmrrom0 r nam we oRan .m.n m m v, <br /> TYPEOP WORN ew Well 0 R.Pkccment Well ❑Well AlkmdnNModificaLLoe O Teal Hole ❑OtMr <br /> iwnlerofWls mbarorhnin <br /> OMktitoring Wella) ❑$oil Borin81s1_ nugoo OGatooh0ial a+mbaolbodny V <br /> O Well IheLmctie0 00uFOfScrvice Well ❑Oro-Of.$ervice Well Renewal <br /> WEILC <br /> E311 New OPvRn leconcnt ❑Pum C. <br /> Ir OCreae .natimR } <br /> ONbT0.11CT1 <br /> Drullrsg Methatl Mad R.my a 0Air Rotery ❑Attack ElCable Tool 13 Push Peict 13 Other <br /> Pr9pned Well Depth S.CO R B.cavition in durreser ❑Open Rotmm Oravel peek/Graved Sia__in diamekr <br /> O Conducwr Casing mdlemela / Condaror Casing Depth R <br /> WUI Caeing Oiemet<rl; V i0 DrickncapOsi evASTMSchad L/0 — 11 Stool '{PlastiC O Stainless Steel 0Orh. <br /> Grouts.. Depth R XNul Cema,,(941bhag/5-s0,u1IioRr) 13 Sued Cement .rack MLT/]gil water <br /> O Bmbvk(20%.IiN) OManuWcma,Spa%.olid,_% Name ❑Specs on File ❑Spew Submitted <br /> Grout Mseemenl Merood 0 Pumped 0 R.Pall 0 Other 0 Remrd.1/Accdoator(name) <br /> PEDESTAL LR9L2kd Her 0 Drilla 0 Pump Conoatar ❑Other <br /> O Corcrete Pedestal DlDaasions: Width R Len h_ft nick in OCbHoy Box ❑Stave% <br /> PUMP 0 Submersible 0 Turb.. OOthv HP_ Pump Ser_fl Sknding Water Level R O <br /> W[LLDWRUCTION ❑Open Bottom ❑Gravel Pack O Uncased ❑Other <br /> Well Diamety in Takl Deps6 ft Depthto Wrter__it )Casingmbe Perforated Rom Rro fl <br /> Sealing Malesial ❑Nat Cement(94 IS beg/5-]Oga,user) Cl Stood Cement_Back mu/]gelw too, OBemosdle Pellek <br /> 0 Seamans(20%.lids) 0 Manufacuuer Spa%.lids % Name 0 Spooa on Filc ❑Spa.Submitted <br /> Placement Method 0 Pamped ❑Fra pall 0 Other <br /> ❑Complete with Mushroom Gp fl bebw grade ❑Ctmtplae U ETieling Surface Pad <br /> 1 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 <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> sDNEo V./Ma�Y_ Tine DAre 3r�L6/03 <br /> tag <br /> App . e' DEPARTMENT oLY <br /> lication Aaepted By /af�/A^'1'C/` Oak Arca �/ �� Employee lDp <br /> Gout Wpcctiov By Date ❑ SPECIAL Well Permit <br /> Pump Inswo OBy Dow ❑ WAIVER Received <br /> Ockmcrion Wpecrion By Date Contracted Well Depth R <br /> COMMENTS <br /> PEZF <br /> SC Realved Chack4f Amount [e Perndtl lovakap WeII IDII <br /> Code, lydo B Cash Rendltal Service twtR <br /> O 57 1225. a o33 <br /> 43?0 01S"7 D Ja o 3 <br /> EHD43.02- M6 MASTER WATER WELL PERMIT <br /> 12W2002 <br />