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10/07/2004 16:17 4640136 ENVIRONMENTAL HEALTH PAGE 03 <br /> WELL/PUMP PERMIT <br /> SAN JOAQtIr,,COuNtY FNvmoNMGNTAL N30413 Wu%R Avs 7-FL-SrocxToN CA 95(02-(264)468-3420 <br /> FI <br /> NON-REMABLE 9T KVJL[ u - �1Sr� l0N3 EXPIRES 1 YEAR FROM DATE ISSUED <br /> PIS: pb%qp n4pri% or Ar <br /> JoaAvoRESe lel ,>i 6d ' rf a crTrrzrr / L O/Ce /App rle C i ftf <br /> 1 oea Srusr <br /> .�f1 A"I-Ir}i's7+(/1�Arcm Stzcy LAno Un ArrLrCAnoN O <br /> Nb + OWNEnNAArr PRlr <br /> C/' 1c CSS � 1/,QGirrl - r,—LbiOw~ r3�sI/M1 rHOYs ••�s- r3�.., <br /> OwNzn ADoRxm 3 A �y� ,�`✓1 Crrr/9TATr1Zrr( J✓ Iy��+� ',v �f g t� <br /> CONTRACTOR 65.E/+ /r�fr <br /> CONTRACTOR ADDRESS t/-Z.7 G1R44'L W. �S,.t�.�� 10= LITVISTATV" <br /> 9t.ntcxlrmtAt:-m,t W r' ptro.�it 707-3�{���,3.v� i <br /> SutieaNTRneTOR ADnteeea P o• Cad pe .3-3 bV' emlSTn,Ct71r V' <br /> LtCCNnF57 LI C-61 OD-09 Qd/t►ha p lVt'AT6ER (� E%PIRATONDATY / / + <br /> GEOCRAFMCALINTOILNATION' Caordlnates X 2 dl/ 3 �����QYerwn�hf � Ran¢ea SKtINO <br /> INTENDED USE ❑DDne laWvate ❑lnigatinn/Agricvltvral 0 Indushiel CL>Virgf%Nifty Monitoring Q Soil SeroplinR Chtrncte*lnuion <br /> ❑PublicWtterSytte lA+F1. <br /> E5n+ ur f�!D-Sp7-�SS7 <br /> rrdi(Rsent*MCJ—m .w runn amt LTi ., 11 .. <br /> Tvr[OF WORK ❑Nm Well ❑RCplRccrltent Wen Q Well Alt=tiarJMedifieaIkn ❑Teat Hnle d Othet <br /> O Monilatit+g Woll(e) t♦of wenn ❑Soil Bming(s) I of N-.Ir ❑(36mcchnlc•l a.rs.," <br /> e 1 Destruotxm ❑Qat•Of.Service WOR ❑Out-Of Service Well Renovvdl <br /> ❑Now IT rUfflp RC leeeMcrt ❑PurrpRePtir ❑Cans-Cmradien R iT <br /> W rLL CONsneeertON � � ger� <br /> Mill"Meed 11Mud Rotary ❑Air Rot" W,g ❑Cable Tool 0 Push Point ❑00VT _— <br /> I'roAosttt Welt Tepd' ft Exwvatimt in ditmrder ❑Opm Battom O 0MV01 Pack"Gravel S® In diemeter <br /> O Conthxror Casl>E a diommet ) CMIMCOr Caain Depth�—ft <br /> WellCOADU D{mnoter�in Tbiclms/Guge <br /> eee /ASTMSe1edSPD4W 71re,0Sttel a ft <br /> ❑Other <br /> Gttvt SMI Depth 111 C Nett Cement(V4 A hog/5.70 got water) ❑Sand Caroazit sock mix/18-1 water <br /> ❑Bentehitd(20%eolids) ❑Manofadtms 5Voe%e011dr_% Nome C1 som 0m F'lte ❑Specs submitted <br /> Grotrt rb=moat Method OpUffrpod ElFree pan ❑Other ❑Relardtmt/Accelerator(na") <br /> PCD68'TAL InathnMB� ©Dnllor ❑"Contniaor ❑Ocher <br /> ❑Coneretr Pedc%W DIMOWIM4 Width—,El ft 'Thick in Q Cbrwy ROT ❑Stumm Pipe <br /> ritiMP ❑submemble 0 Turbine Q(met Hr Pomp Set ft Standing Water LCvel rt <br /> WRLL DIIRTRULMON ❑Open Botwtn Q Gravel peak C'umAsed 0 Ocher_ <br /> .� Wall ni,;; m Tout Nrth ft Do*to Water A O Caping to be I'dKmted from ll 10 R <br /> Scaunp,material (94 th hW/5.10 gat uuter) ❑Sand CwNgnt a�k mh/^,got water ❑Bra tonne fell ED <br /> 7-f <br /> 13Bento��n.itm�(�220-.% ❑Sp�3*46) Q Menufect Drat Spec�k E011da ❑4Txcs onFo eer:Submitted <br /> plRetc,"t Method 4tampal ❑FreeFall 13Other <br /> ❑Com lote with maif m Cap ft below D Complete m ExistinR SitrN a Pad <br /> AAr:[i 1 IIFRt?BY GERI]1rY THAT 1 HAVE PREtARRD 7RT3 AFpi ICATTON AND THAT Y]I£WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> t JOAOUIN COUNT\' 0RDT.4ANCE5,STATE LAWS,AND RULFS ALND REOL1,ATIONS, T ALSO CERTIFY THAT My REQUIRED LiC1r;NSE IS <br /> P,77— I CIIRAPINT AND AC rVX WrM THE CALIFORNIA CONTRACTORS STATE LICENSE SOARD AND T13A1r 1 AM IN COW1,11ANCE WITH AVL <br /> r;� — WORKERS COMPIt,MSATION LAWS <br /> �rv'1M4UrNi.z41�1 6VAPIC'F NOTICE RI;QUTRF,D i+OR INS�a��s <br /> c4 <br /> t <br /> r0 u TDitt ARO L 1, — <br /> Al plimtion ACCCpted By �j / �__ l�It l Per ee tlNi <br /> Grant lntp<dinn Hy _,_� re t` ❑ SPECLAL Well PC1'rRtt <br /> Isump Impetti0n Rv Dote n RrATVETt Received <br /> Camtraeted lydl Tt <br /> DQIItrIKtlan I tion B D„te <br /> COMMIIIS� Dr cL'f ��C �s �ur'rn�� duffle 'il'raMkX � <br /> J r� <br /> pg 5C Rem vett Cdrrk� Arnoont F W InvMcc ii WOn TDP <br /> �d �rC $ezviR R crt 11 <br /> Codes IMo h omitted <br /> T Qr <br />