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r <br /> WELLIPUMP PERMIT <br /> �Cc EAST M&IN STREET.STocRToN CA 06202 .(2091469-3420 <br /> S►NJOAoIHN Co_Y ENVIRONMENTAL HEALTH DER ARTMEN' N <br /> NON-REFUNDABLE PERMIT CALL_209)953.7697 FGR INSPECTIONS—- <br /> _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDREs3 ,�A -2069-51-TRAPf-, 7��I rRCEL SIZE �0� LAND USE APPI.CAT+ON a_ <br /> � <br /> {1 APN <br /> CRO33 STREET PHONE 1� <br /> �=4i u� 1 y 7 <br /> �OwNEA NAME C-ISTATFIVI' ���-]�17 �f,_�-------- <br /> towiiER ADDRF39NTRACTOR <br /> jCOMRACTIM ADDRESS <br /> 13ulCorni ACTOP --- ------ -- - -- '--` <br /> CITY/$TA TEf2tr <br /> SVeCoNTRACToP ADDREea '- <br /> ER <br /> - EXPIRATION CIA <br /> A+E <br /> LICENSE C.57 i1/C•81 �D-09 --_...NOT <br /> Y Township_ Range Section <br /> —�:--. <br /> GEOORAPleCAI INFORMATION: CootYlttietef X-�-- <br /> !i INT LADED UBE �DORWSticJPllvete IrfigauorVAgnculWiel _-- WetRi Ouahty Mnndonnp SOII Sempkng/CnSraCtM2eIlOn <br /> Public yyater Sm <br /> C- tl ARererR a'Rrn ryste'.1 <br /> Replaceent We9 Well AlterenonfModA(:8IIon Tw pc Omer <br /> � New Well ma of tn+RgA <br /> Tune of o .Pt GeolechmC81 <br /> r MonilonngWeets) iolwells So++Ro-Serv,l <br /> �0�u�j-of-ServliUut-0l•Senr+tr wee RenewalCross-Connectbn RePeuRaise Well 0811 Re ecemenl . Pump nELL CONSTRU <br /> Ddlilrp Method Mud Rotary Air Rotary Age, Cattle Tool Push Point Other `— <br /> in d+emeler Open BORn Gravel PaCk/Gravel SIZe in®errttlNl <br /> 'Proposed Well Deph a EMI vellon ___ 1 <br /> Conductor Casing - <br /> P.dlarnetel I Conductor Casing DeDih .---It <br /> Thtckness/Gauge/ASTM Schad Steel Plastic Stainless Steel Omer <br /> Wel'Casing Diameter gar water; Send Cement sock.-^nn pal water I <br /> Grout Seel DePtn ft 1 Neer Cameni(9e It DaV5 T(t 9 <br /> 6enlon4e(20%sOeAs) 11 Othe+ — <br /> 1 Free Fall +Other _ Rtleroenl Ar,Celeralor(name) <br /> Grout Placement Method 'Pumped __---... —�------ <br /> PEDIMAL Installed By I Driller i Pump Contractor -Otnft---- 1n Christy Bok 1'Stove Pipe <br /> C concrete Pedestal Dimensions mndln n Lengg�n _ <br /> - deng Weser Levet <br /> ,PUMP *Sulm+arNb/e I'ru:0lnil :.O,E;�,.._-.-T---HN.r _a_._ _..._.._. <br /> PI1mp Set _ten Step <br /> TH <br /> I HER <br /> BY C THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOP SO ICER BE DONE INMACREOQUIREOELI ENSEtS <br /> JOAOUI OUNTY ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS <br /> STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH All <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS i <br /> WORKERS COMPENSATt AWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE RQEQUIRE/DFOI'R-INSPECTIONS <br /> TITLE DATE-_-' <br /> SaEaD <br /> 44 MEN7 <br /> -r-? ---t.. R <br /> EIYe <br /> 0E P A R T M E NT U/SE ON/L" ' - <br /> /�/'• <br /> Date e" _-----_ �i�-i-j-; A ea_D � Employee ILS 4 _ .7 <br /> Apptltatlon Accepted Ely pale -/t2 SPECIAL Well Permit('rout.nspedlon BY Dote 5 L 3 WAIVER R@C@IV@d <br /> Porte 1m lon BY �'-fJ- CoMtrLated Well Depth R <br /> Delo - <br /> Soa@aAnp:n BY <br /> COMMENTS _ - - ---• ---- ---- <br /> ..:..+ -JAmount I Pormly invoice a Well IDO <br /> PE C Received ec - I Date Seryice Raquast w <br /> Info <br /> as Remitted /-- - <br /> Coda B /c00 f.7 0I sem <br /> 371 <br />