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lye(-1 NA� ��n �7-�!'7`—`b '✓J/ WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'BBB EAGT HA!ELTON AVENUE-STOCKTOX CA 95205-(209)468.3620 NON-REFUNDABLE PERMIT CALL 209 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FRcM DATE ISSUED 72�9 n JOB ADDRESS D GOT/LP I O 3 �j� CROW$TIIEET_fL 9 � APN I)I7— 4)2�0— PARCEL S6E !_30 LAXO USE APPLICATION# a OWNERNAME lvr SPl/l G!/ry / PHONE OWNER ADORERS y7!/J� �//O/ IC_ C�_mATAT)ILIZIP CONTRACTOR (/Ii9,T�//I�/A'L/ � �/.V/2 �]. PHONEA /��'fLK�✓�S,/�� CONTRACTOR ADDRESS yy// CRY/STATF2 )� 1P t /r er.� S LN SUBCOMMACTOR PHONE SUBCONTRACTOR ADDRESS r✓ CrrviSTATEMIIP LICENSE V C57 L C61 U D-09 a Other NUMBER 764p EXPIRATION DATE GEOGRAPHICAL INFORMATION: COorOlna1W x Y Township— Range Section_ INTENDED USE XDomesticrPrivete - I nigation/Agricuttural ❑Industrial ]Water Quality Monitoring CSoil Sampling/Characterization u Public Water System IldamertNom Ownrem arm o ..—.1one um r TYPEOF WORN [New Wall L Replacement Well a Well Alteration/Modification U Other D Monitoring Wells) #of wells EJ Soil Borings) #mcodn"" ❑Geotechnical #ol NPmgs ❑Out-Of-Service Well ❑Out-Of-Servioe Well Renawal 0 Cross-Connection Repair u NEW Pump L PUMP Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Methotlk Mud Rotary C Air Rotary C Auger ]Cable Tool 0 Push Point ❑ Other Proposed Well Depth_24,0 ft Excavation 4j;L in diameter U Open Bottom a Gravel Pack/Gravel Sae in diameter n Conductor Casing_in diameter / Conductor Casing Depth It Well Casing Diameter-,4,in Thickness/GaugeIASTM Sched n Steel n Plastic n Stainless Steel T Other Grout Seal Depth /clip ft C Neat Cement(94 1b bags-TO gal Water) O Send Cement sack m1xO gal water XSentonite(20%s(Vids) L Other Grout PlecerrlerMMethod XPumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ]Driller C Pump Contractor ] Other ❑Concrete Pedestal❑Dimensione:Width Contractor Length ft Thick in DChristy Box ❑Stove Pipe PyMP ❑Submersible]Turbine C Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 911HDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND AC V (ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPE (LAWS. MINI UR ADVANCE NOTICE REQUIRED FOR INSPECTIO S-Jp,L SE CALL(209)95)3-7697 SIGHED TIRE �nG�/-'� � DATE /O&--// IIVAIIII 11111111 11111111 . A 22 ogo��N c��16 H pE qq�Nry D` ARTMENT USX ON Y/ Application Accepted Date Z EU( Area Employee l0# jr7: . O Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil BoringIns ion By Date C�,$Qnatructed Well Depth ft COMMENTS . PE SC I Received Check#/ Amount Data Permit/ Invoice If Well ID# Codes Indo B Cash Remftted Service R uest# All s EXn L109 WELLPUMP PERMIT 4130112 I�I7/s