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30 2017 01:42PM HP FaxWkns Pump/ Knick 2098488118 page 1 <br />®e Aad, --, 30. 2G 17 H:25AM <br />e No, 2191 P. 2 <br />111f' WELLIPUMP PERMIT <br />BAN JOAQUINCOUNTY ENWRONMENTALHBALTNDiPARTKfNT 1088EAATNs LM.AI^ u..ra„�.,. �..� <br />NOPI-REIFuND <br />Jly AetOtri! <br />CAOSS ET1106T <br />OMEN maw C <br />OMMER ADDRESS <br />�nttucTORADDRlSS <br />aCONTRACTOa <br />AMR500 <br />57 L C-81 <br />D-00 C <br />TALL 2OAY /933.7a/97�FFOOR INSPECTIONS EXPIRES <br />'I YEAR FmOM DATE I80UEC <br />A. -N PMCEL91g LAUD USP Arrt(G1143M# <br />FBONII�� , -.3 <br />C rM�SrarEllrr W <br />PNONS <br />Cfn/STA"zMr <br />NYN301 2 Fl1aIRAT10N W1TE <br />" u J <br />_•-yr•-•,-�,�•v' .,.+: "oranrm"t Y Townehlp_ Range_ adojon_ <br />INTINDIVID UPI DomMItWllvsds r' Imyalron/AyrlcuRurel 17 IndvfJrlN !' We1lrCluelR <br />et� V MMMAm <br />g `: SON 3aMpinprCneytyrl�Uen <br />1� %1!Wsie ro'r— <br />/l .me o. ly .. <br />1YR! OF WORN f-Vfw Well ^ RepIOCOM"t Well 0 Well ARenli-bIUM0614orlon C Olh« <br />r, MonlmnrC wdo(11 ADl werls r1 Sam Sor1nAfe) eaeonOr 0 Aedeclnical e`�"`^"o' <br />Out-Of3evlca rWal V Out-01-SeMoe Well Ronamral 11 CroeaConrreclon FI RPell <br />I -i hlear 0, , "unn Roplawn en 1. ❑ Puna Rewlr ri R.I.. Wdi `..v. <br />Dr11fnS Nh10od (, Med Raley ') Alr 116" A Auger I? carie 7e01 Push Pohl I . Olhar <br />rropoeea w I uaplh t 4:10YAtlOn Indlemeler C Open aofavn (, drawl Peckr0raval Bloc In dlemetw <br />t Canduetor Caeing In dlefPCILM I Conduct" Ceaing Depth R <br />Wall Ceelne Dlernew _ In Thlckmsj(3IupWA87M Schad_ ❑ W2W r, p1M110 I' 8telnlxs 61e0 1. 04h■r <br />Oraut aW DOPA -11 Neel Ownanl W Ito DedS10 pal ow9r) 11 8ord Ce/nanL sal mW7 Dal walar <br />Ii 8"wih1(20Y. Soda) . a otor <br />GroutPlacesoea)IMdwd oPumped nFreerag 11Olhor t RatardantlA0ce10rator(name <br />ELDIATAIL Metalled By i) Drllor !1 Pum Ca,**.Io, p1- O{llar <br />G CanenW Peeteehlf+Wmensl0nr Wldlh R LenQlp Tnlck In r ChrlWOL n 6taVa Pipe__ <br />ur �A,a,m•rdur.. Tudin. -r etA. F�► Punq a n aurdI1q Wear LayEl AQA <br />I HFRFHY CERTIFY THAT I HAVE PREPMFD THIS APPLICATION AND THAT THE WORK WILL EE DONE IN ACCOROANCE SA <br />WITH N <br />JOAOUIM COTY UNORDINANCt3, STATE LAWS, AND RVLE6 ANO REGULATIONS. I ALSO CERTIFY TNAT MY REQUIRED LICENSE Is <br />CURRIENT ANO ACTIVE MATH THE CALIFORNIA CONTRACTOR! STATE LICENSE BOARD AND THAT I AMI IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, <br />PAY�E� <br />RECE1 <br />14V11a OhAfaepWdBy <br />Grout Inapealon By <br />Pump trop -Aon By <br />sd1 acing Inepeaeen Bt <br />COMMENTS _ <br />A <br />p <br />IT <br />Z <br />rn <br />MO <br />AUNT USE ONLY <br />C <br />Data I) I " I <br />AraeBmplDyce ION'�t r ln�� <br />m <br />Z <br />OA:► <br />f�T,I <br />C <br />r I <br />S r <br />t0: <br />Data <br />-� <br />0 WAIVER Recelved <br />^ = <br />pV <br />M d � <br />1•� <br />Conelrueled Wed Depth 0 <br />j�/�iT�Y <br />y <br />x <br />'T.ir e.'hy <br />uxv '1,— <br />WHLROW rERYn <br />Received Time Aug,30. 2017 2:48PM No.2195 <br />rn <br />AUNT USE ONLY <br />C <br />Data I) I " I <br />AraeBmplDyce ION'�t r ln�� <br />IV <br />Dale <br />❑ SPECIAL Wall Perth <br />pp <br />�� <br />- <br />Data <br />-� <br />0 WAIVER Recelved <br />^ = <br />pV <br />Conelrueled Wed Depth 0 <br />C� <br />uxv '1,— <br />WHLROW rERYn <br />Received Time Aug,30. 2017 2:48PM No.2195 <br />