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WELL/PUMP PERMIT <br /> SANJOAQ01,COUNTY ENVIROMMENTALHIIALTA DWAVIOM 304 E Wtm Avr 3"PL-Vro"ToN CA 95202-(2")4W3320 <br /> NON-REFUNDABLE PERMIT CAIA,(2"953-769',roil 1-%%rEcTio%s EXPIRES I YEAR FROM DATE ISSUED <br /> 40NAD"L&I- ------ t! fCt" <br /> > <br /> Cium SMET <br /> P.4* Ci.sin,C 1 Y &0Use AMX*ATl0N9__ <br /> OV/NER AAML Jf <br /> OwNra Aw*r,% ------ <br /> !CO ."Ac.,roa kif it <br /> A Ai, <br /> CONT&4crou CjrV15TATLrDP <br /> MISCONTUACroft <br /> SMA"Wr"CrOM ADDRESS--—-___ Vrrylil ATrj7jp <br /> !t,#M.4sx 0C-57 CC-61 0 D-09 )tOdw JZAt� <br /> A f_ NVWKjk ?TjZL__ E9P13tATXWbATXa�_ <br /> GCOGItAPHICALINVOIAMATIOIN'. C66rdt"gn X V Tawmlilp_ Rjk*W__ <br /> I=LUWLUR %DomWielft'vitte Q ltriptWWABtkultural 0 Industrial 13 Wstef Quality MOMU)"119 0 Soli Sampling Ci arsct�oat at+ <br /> i 0 public Water 9= <br /> No <br /> -fart Of Wtxtlt 13.4tw well a Reptueen"t Well (3 Well Alzr4ionlModifitalion 0 Giber............. <br /> •Monitoring of web OS 1sorives).........................­..". ofwiei 0 Gnowchniol— <br /> •Out-of-sevzo;Ll,lty <br /> 1 a Out-Of-%, Vykt Well Iteriewal (3 CrC41-corrocuon It"ir <br /> 0 New Pump Pump <br /> t;3 Pump R4 , <br /> Pw <br /> , <br /> Diriltioll Method 0 Mud Rotary 0 Air kc,"ry 0 AUW 0 Coble T*01 0 P"),h Point 0 Other.................. <br /> dw,.w_ <br /> Proposed Wall 0cpth Exetivano" in dijaritter 0 Open Bottom 0 Grtvti Pack)Gravel Stat„ ", <br /> 0 Cciodactor Ciuring in diameter i Ctinduttor,Casing tkVh ft <br /> Well C&4*g Dismew_in '1Tx:imes&1GAurJASTM Schad....................................... 0 Sim 0 Plwax 0 su-iiii"s Stec! CI Other,_____ I <br /> Grout Sell Depth It a Near cerricin 1`94 lb bogy 5-10 goi)4wrr) 0 Sand Cement X�,k-or 17 V,wow It <br /> ................. ;;r <br /> 0 Sentowite(21?/#solids) 13 Manufacturer Spec%solids........... a Name............— OSpws*nfile OSpecs Submiruid <br /> GrowPhtevmeat Mehod opumped orrecfall 0 Other Retashint;Accelennor(nAmt) <br /> ft"STAL lotuilbd By 0 Driller 0 Pump Coatiactor 0 athcr <br /> 0 Couertft Pedit" Dintesmiew Width It Lzoo—it Thick.......,.„...............in r,CbfWY SON 0 Stave <br /> 5S!!t2!ntbk 0rutbine 00thwHp pump Sit itSuirsiliq Wim Level <br /> tom_ rt 1 <br /> _J� Sit _ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQVIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS, I ALVA)CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH TUC CAUVOMIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMMIANCE WITH ALL <br /> WORKERS COMPENSATION LAW& <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> e t 41 DATE <br /> _T <br /> T_ > <br /> ........——— <br /> I I I t <br /> Ti— <br /> it TPI-IT <br /> DEPARTMENT USE ONLY <br /> D- Ams Employee IN <br /> Grout Inspection By SPECIAL Well Permit <br /> Pump Inspection By Dabz4z C3 WAIVER Received <br /> Covoitructed W pth <br /> COM BENTS 'a.., —---------- <br /> 7- <br /> PE sc kfteh*d <br /> Dow Invekto <br /> codes Isfa By _ca Rtatitied _Sitrvict tet ow <br />