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WELLIPUMP PERMIT 10 '* END <br /> Uree <br /> SAM.)OAOCOUNTY ENVIRONMENTAL HEALTH DEPATRaW im EAsr HAULTON AVENUE•STacATON CAm �) <br /> NON-REFUNDABLE PERMT _ CALL(209) -7697 FOUR INSPECTIONS EXPIRES 1 YEAR Pitbii[SATE ISSUED <br /> .ion dibUREAS 1✓ CTTYJaP 1 161-MC y <br /> 'CROO.s STREET APN�' PARCEL SIZE L-A-M0-Usee APPucATWN i <br /> OtNwENNAPE <br /> OWNER AntWeEes pC.S G } .3�y� t t'�TY15rATEtYtP �c;L"�NSc'y'I C[�CP t�-�3)i�a.� <br /> Cw1uCTOR �tdtt t r YYS ��/ yd PHONE <br /> CoerrRACTop AOoxf." i /`t. vV1 C vEs lY /� CI TYrSTATErLP i4Y9 <br /> i <br /> Sus,..A.TOR _ PHONE <br /> SIM'ONTnACTOR A000611s __ CrTy STATvZw <br /> 11+cc ISE G57 }�C B! C.U9 OTtwsr Numma-j,v T 1 Ex TIM OATE J D r Z ti <br /> 'I <br /> DoetEsnc WELL SAaIPLWG: GerwW MowaUCokform Batten(•1391)(',i Dibr=ochloro)xoparie(4392) _ Amwic(4393) <br /> W stftlPriv s i J IMOMWWApricu tura" lnWs*W 0 Water Quality iAwOw ng r SO#Public Water Systam <br /> I <br /> H dJbr ofn O>+n+r. Wear 8"*-Nwrw Cor#acf Ne M PNM N-WAW 1 <br /> MMe OF Wool( New Wel Reptacyrrowit Wei Wei AM*r&dOnA4odiu bet t')Down __7 <br /> Monitoring Wait*) a of Wells :Sod®or"(s) e09, . ..GeotedUuCali edr„rnp. <br /> but-C7l-SurWct Wag '.:'0(0,0l-Servka w*1I R*ri*vw ''l Cro**-C.arrrarct3an Rapr�r <br /> P R P Repair <br /> Raisa Wei G <br /> W,�ya.Catt*7ttu4Ttd+ <br /> Drill"ilethod 1,Moo Rotary Air Rotwy Auger :.Cable Tod Push Pow Citl'Isi' <br /> ;Proposed Well Depth ft Excavetlon in diameter Open Bofti Gravd PaduGravei Size in a+wn*trr <br /> Conduaar Crainq M tteanater I CaWuraw Caring O ep!M R <br /> Well Casing Diameter_in ThIcItnestKGaugeJA57M SchtU Stem Pkrctic Sim-At"Steel Olritr <br /> Grout Seai Depth-ft 2 Nest Gernert("Jb DaptSTO ON rele,0 Sand CamwH Saar>✓u17 gal water <br /> Berton"(24%solids) L'Ottwr <br /> Grout Phceenattt Medved Pumped Flee Fai I Otho' Retardant t Acceferexor(name) <br /> EiVkTAL Inetaied By ;;Od lar 'Pump Cwrrr*ctor (wwyl C <br /> _._..._.-_ Concrete,Pedeahl:Ilirnsrreaiwre Wdlh _h Lengdt n Thick inChristy Bus Stove Pips <br /> I[ Turbine .:Ottw HP Forret 7�±_ h Standing Wrier Laves R i <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK VALL BE DONE IN ACBWI <br /> E TH SAN <br /> JOAMIN COUNTY ORDINANCES.STATE LAWS, AND RULES AND RZOULATIONB. 1 ALSO CERTIFY THAT MY REARED LICENSE IS <br /> CURRENT AND ACnVE WITH THE CALII'OW"CONTRACTORS STATE LICERM BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI V jM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95)1.7697 <br /> SfCNEO TITLE �"`.✓w+n C✓ DATEI •Lr�1 <br /> fvc MENT <br /> EIVED <br /> I it <br /> iL_. . i2 3 2019 <br /> 1 iii <br /> + i I 1 UIN COUNTY <br /> RCN�iMENTAL <br /> I I 1I DEPARTMENT <br /> I <br /> PJ4RTMENT USiot OJNL.Y <br /> ,}�' isyne <br /> ApplirmTiors Attxptb8 By' Area <br /> I By j�-.. <br /> Grout OoweECIAL WeilEmplIrT <br /> Pm tyE <br /> p—p ihspemon 8y �c:Y Data WAIVER RecOIVSId <br /> Soil Boring Inapedion By <br /> Data cwmtructod Wei Depth tt <br /> G WMENTS <br /> i PE SC Raceivad - Amount PermtU A VMep <br /> teNo B _ a I Service R*Wjou a <br /> ilS7 <br /> M4340 &VIM WEiI.+PtMIPPEaWT <br />