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WELUPUMP PERMIT <br /> SAN Jin oam Cowin EwinowmTAL HEALTH DEPAt Tmw 1689 EAST HAMTom AvENm-SroacTon CA 96204 4232(204)"83120 <br /> ' <br /> NON-REFUNDABLE PERMIT wwwskov.OrWOd EXPIRES 1 YEAR FROM DATE ISSUED <br /> X09 23649 E Harney Ln Crnrrap Lodi ' <br /> CR=STro3TAI&MOXI/Al AM 067-040-090 <br /> - PAFXEL SZE y(S--LAW USE APPLrAT"3 <br /> DVAaRNAW Berghill, LLC PHOW209-888-5465 <br /> PO Box 3 CrTY1STATSf1P Linden, CA 95236 <br /> cTnmt Purviance Drillers, Inc X209-887-3554 <br /> 95236 <br /> CamvrAAcrak Aaos>:ss <br /> PO Box 64 CMISTALinden, CA <br /> SURCONTRACTCRiCONSULa t <br /> TWT n <br /> TANr AtmREan n./a CrrrlSrATr� <br /> Lr� %C-57 ;C-61 0 D-W c� MXAM 377923 F�wrtATtam wTs 7 l 31 J 21 <br /> Bsyao PALM: OVAGM CowntACTuit - u- <br /> DoMes7Tc Wet SAxPtsatd.C Caenetal kttneraVC fiform Baderw(4391)_'DbromochbropropRIV(4392) Arsenic(4393) <br /> DwwgbWAMM X t nftVA ;-;Is>WtWfat (:MWQu@WMoni v-V ❑So9SWM&XlChoraC�traaon <br /> -.Public Water System cmama N—or prro tb vw <br /> o dakwd dom Ower wtar symmmme NNM <br /> VE � <br /> TYOs WgAW �New We4 i-Roplwment Wei -Wo&A � "Omer rnA j <br /> 3 of weft C::Sal BaMVS) s dAamv C:Geo> I •a Doug+ ���)ny,,•��� <br /> 'Out-OE-Sen+icx Wd ❑Out-Of•Sarvice Nh@ Renewal _i C+Ow Repair <br /> New P u Pump Replawmant P R �-Raise Weil <br /> Watt COiaOT#t4F2tQN O <br /> DM[kmy Method XMud Rotary UAV ROMP :Aul;w _ Cab{e Tool L-Push P001 1. oamer <br /> (Proposed WeR Depth/" it Ez , -1.2 _to ,B oW sotwn Grnrd Pa6/Graust Sim in <br /> cormdnaw C8*V 6_h dlema w 1 Carmducior Casing Depth <br /> We#Castnq Dwrater[fL in Thitknewnw-pe+AST'M Sdmed .?S,o steel wasac Jhstse fess Stem r oew H DZpM�TM <br /> Grout Seel Dept�! !2Z k Neat Ca ment(94 m Da015-10 0 wader) -A SwW CerrmM !O.3 $a&--v7 pal wale, <br /> Grout p%"mant Method jj Pumped a Free Fd r Other Retm i Am4eceW(reow) <br /> PEDEVAL kesLOod By )6 Driller C;Pump Cce*semr C7 Other in �Christy Boz D 84ow PIDe <br /> It Cortcrsb Pedestal 0Dimersioru VAdlh A Length <br /> PLe+sL SumW30AU Turbine "Other HP pump Set R Siarmdirq WaW l R <br /> I <br /> HEREBY CERTIFY THAT I HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE YYITIi am <br /> CERTWY CURRENT AND w £ ACALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AMIN COM <br /> T REQUIRED MY PUANCE MTN ALL <br /> WOmmm COMPENSA <br /> MIN LIM U ,MANCE NONCE REQUIRED FOR INSPECTIONS-PLEASE CALL(2109if-To 53-7 97 <br /> C,orporate Secretav-w) <br /> I <br /> 3 <br /> � i I <br /> i u <br /> i <br /> DEPARTMENT USE ONLY <br /> Appk"-Atxapbd By /,Z, t Date that J Afea Employee ID8 DA- <br /> D� SPECIAL WOU Pemtit <br /> Grout InpW-B :1WAIVER Received <br /> Pump irup6ctlort By Y baro <br /> Sad Bodrq km--,Z-By Date Canahttcted WON Depth R <br /> COMMENTS <br /> isE Sc Received Amount Date �e Mvoiu• won N0/ <br /> Cads )trio Remitted <br /> N�Ett,vurr�mTrar <br /> END43-M En7Wt <br />