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02/24/2004 09:27 2094683433 FIFTH FLOOR PAGE/ 02 <br /> sANJw Tl +ALX./PY NII?PERMIT t �' C� J 2-o'L4 Y� <br /> I;URJ COIIYIY CNvtkCNMRI `�` <br /> NON-REFUNDABLE PERMIT >vtutuDErnkTMsvr <br /> CALL 209)953-7697r0R1Ns,PECTION3otLE�&RnvSJ•^�.-S7oCKroNCn9ezo2•(209)'"S.Un <br /> JoeAntm>;gq 27,05' Cb j� /1� �pIRES I YEAR FROM DATE ISSUED <br /> CROSS STREET `' CITEIZtP=TQ 9sa o m <br /> OtVNJ!St A,mX LC.?ff G�p Apv P"'Acu SIZE <br /> OWNCR"bmE t 3oPNONE a�9"/p r------ <br /> Q G <br /> CONTRACOR " St47t CITrisrATE/Zn• s I-a— y c+ <br /> CohTRACrOR ADORBSSCr✓ /V 1SL!S/ �,. PHONIC <br /> rJrsS j� <br /> Slt9CONTRAC'rOR CIt1'/STA7'¢/21r Del/ <br /> SVOCONTRACTOR ADDRF,Ss PHONE O <br /> LICENSI; OC47GI CITris7ATEMP <br /> QC. <br /> O D-09 Other <br /> C, 'O!C WWCALJNFORMATJrah NUMBER OZ Ear1RATlON'DA r Cie <br /> INTEfiDgOUsI;- O'" 111111111111 Est <br /> XDatncst&d)Rlvnlo V Towuahr <br /> OInIg1� tAgricuhural OladuslrGll b' rbc Section <br /> d Public W.IorSvstcm O Watcr Quality Monitoring O Soil Sum lin <br /> Ifdt.tm none tavner; P g/Ch^rnatcrication <br /> ntgOFaor rtrcm m e <br /> WORK ONeoy Wc1I ORcplaeunant Wallow,ei ,rM o, owr w^ur <br /> Cl Monilaring Well(:) .Wbvarwqis13 Well AltccuioNMediReutian O Test Hol. O Olhor <br /> Cl WCA Destruction O Soil Boring(,) nuntb�rafeo6ngr <br /> OOut'OsLsorvicewell 0OLVIochnical ^amCcrvfbomay <br /> O New Pum O Pum Ire lieenlcat O Our <br /> DrECLCOhS1RU (]Pum Ge,Ur -con ice Well Rrntwttl <br /> DeJlling MO(hod O Mud Retn O Cross•Conncetion Rc nir <br /> Iy d air Rotary ❑Auger O Cable Toot <br /> Proposed well Depth d O Push Point <br /> R Excnvution`1`� AOthcr <br /> ❑Conductor Curing --r d,di"mater Open flonom O Gravel Pack/Cn <br /> Well Cassn6 Diameter —I^dASTMr / Condtrctor Casing prp h cl Si" _ia d!>tmeler <br /> _„in 7hickta./Galttr;rASTM Schcd -11 <br /> Gmur Scal <br /> DepthO Nat Cemet(Pi_l5 ~'— O Stccl O Pasic O Switloss_S. <br /> IOIO Bntonite� 4 15.J0gVfWoo) <br /> D Othcr <br /> $ O Sand Comem <br /> —GroesPlaeamcnrMethod OPum cs FOManuracturcSpot%..lid, <br /> rog pY. Name " lack mx/7 gal <br /> wat <br /> r <br /> O Rcwrdonl/ACcGcrmar(namt) onP lePEDgyTAL aO Other OSpocs 13SPecs Submiltedt. an O Driller <br /> O Pump Contractor <br /> O Concmto Pedc91e1 Dlmentiona: 001hcr <br /> PUMr 13Suhmmsiblc Width— 0 Lencth R <br /> O Turbinc Thick_ In O C <br /> WEUpFRCRION 00lher UP— Slave PIP, <br /> O Open Bottom O Gmvcl Paal, �mP Sa� R 9wnding Whrq,ty Baterox l.cvo)O^�8 <br /> Wcll Diameter in Total Depth d Uecased O Other <br /> Se9111119Mat.rial O Nat comont154— <br /> Jl Deysh to Wilor� ft 0 Caaing to be Porroratcd from <br /> (eN/G Gay/sJlr gu/Wars) d Solid Cemene R to R <br /> OBentonite(20%gol;ds) 0Menuruevd oock^"Y/7S"Iwater O <br /> Placement Metbod O hurp� Spee%gout!% • Name <br /> 8catonitr Pellets <br /> O free Fall O Other O Spees on Pilc O 5yuc S„omitted <br /> 0 Com lete with Mushroom Cap <br /> 1 L REDY CERTIFY THAT 1 II below rude O Complolo to Exivin <br /> JOAQU7N COV.riTy fLAVKt'ARED THIS APPLICATION AVD THAT THk Vyp gSurfaccTad <br /> CTIVE <br /> CURRII Pr AND COMPENSATION <br /> WITH T. 1pORNIA CONTRACTORS STATE t fCENSE DOgRD AND TUFT 1 AM 1V COMPLIRED WITH <br /> ORDINANCE,T,STATE LAWS,AND RULES AND RE WORK 1 ALSO CERTIFY THAT 1111 REQUIRED LICCNSE IS <br /> RK WILL BE DONE 1N ACCORDANCE WITH SAN <br /> WORKE]tS COMPENSATION tnWS <br /> IN1M 24 HOUR ADVANCE N(YrICE: QUIRT%,)FORINSYEC'r1UNS ALL <br /> f <br /> TITLE <br /> DA72EZ 271,9 f <br /> Application Accepted Dy DEPARTMENT USE NL <br /> Grout lasp olion By Date 4'I- Arca PmPtoyco IDN <br /> Date`s 13 SPECIAL Well Permit <br /> Panp[nxpeetion By <br /> Date 17 WAIVERReceived <br /> Deatn/ctian IMPcc6on By <br /> COMMENTS Dutc Cnnytructed Well Depth R <br /> PE SC Amount Cbce4D/ Rttieired — ^` <br /> Codes Info Remineds r By Dude ParmiU <br /> Ser Acc R uest R Invoice 0 Well]DM <br /> 3` 4 cc / <br /> EHD43.02-006 MaYttr WRlcr Well l'cnnit.doc <br /> S/2W2007 <br />