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WELL / PUMP PERMff S.' yr <br />S,i.�dO:iQUL�COUNTY ENI'IROIYJ1fEnTA1. TY DCPARTMENT EAST MAWSTRUT- STOCKTON CA 95202•(389) 468-3420 <br />NON-REFUNDABLE PER [,//{y y/ R ,PV EXPIRES IYEAR FROMDATE ISSUED <br />JOB ADDILGti.S u"`' � l t y�,,/�, �' 4 2 [ 1 1 D 1 <br />CWOSS STREET `�`�F� i APN - K1 g <br />' --- PARCELSIzs i <br />OWVER NAME <br />PHaxEbg- 7 -3 55 <br />OWNER ADDRESS � d� �oX 3 2 3 S7-06/67-0 AJ, 01 R'5z / 3 j <br />`� -- CITY/ST:\TPJZIP <br />CONTRACTOR (� t'r"�/ � PIIONE_E�/'+ � p <br />CONTRACTOR ADDREW�(�..�,�%Z_ >^.�I�l l�Z � CITY/SCATEILP <br />SUDODNTRACTOR PHONE <br />SURCONINACTOR ADORE88 CITY/SrATEatP__ <br />LICENSE OC -57 -61 D" D Other NVAISER ECP1R1T10%D.iTE _ <br />GEOGRAPWCAL INFOR t:\TION: Caordl.,. X Y' Township._ Range Section <br />L\TENDED USE D Domestie'Pnvat, D krigatiow'Agricultural 0 W&WQuality Moaitoting D Soil SemplingCharactertzation <br />17 Public Water System <br />LLidihiT�9t aec:Okuc: =V Sluam name Comas Vama or l5hon Vamber <br />Ti Pt. Ot ibostK D New Well D Replacement Well O Well AlteratimuModilication O Test Hole D Other <br />❑Moni,WingWeJl(S)mhmtcrotwv11, 0SW1Boriog(s) 0Geotec6aical numSr•arSwcag: <br />13 Welt Destruction O Out-Of-Scrvice Wei; 0 OutOfSenicc Well Renewal <br />-- — - u1. r155K. onpL'CIIOA K. <br />WELL CONWPAffr,O <br />Drilling Method O Mud Rotary D .fir Rosary D Anger O Cable Tool 0 PL -A Point D Other <br />Proposed Well Depth fr Excavation in diameter D Open Bonom Cl Gravel Pack i Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _in Thicknes.'GaugvASTM Schad D Stecl D Plasdc D Stainless Steel D Other <br />Groat Seal Depth t) D Ncat Cement 1941b bag. S-10ga1 Wwer) 0 Sand Cdaxat sack mix %7 gal water <br />D Bentonite (Mi solids) D Manufataurer Spec % solids_ o \spa D Specs on File O Spec Sttbttrinad <br />Groat Placement Method O Pumped ❑ Frce Fall D Other 0 Relardaw ; Accetentor (name) <br />PEI)E57AL Instilled By O [kilter D Pump Contractor O Other <br />0 Concrete Pedestal Dimensions: Width _ ft Length— ft Thick in D Christy Box ostovepipe <br />Pump CJ Submersible +ifi. Turbine C7 Other HP �� Putt S¢t �7Ci ft Stsndmg Water Level ft <br />"'LLL DtSTRV" 10.N D Open Bottom D Gravel Pack D Lwased ❑ Other <br />Well DiamLwr_ in Total Depth ft Depth to Water ft D Casing to be Perforated Rom ft to ft <br />Sealing Material D heat Cement /94 lb bag,' 540gal Miner/ ❑ Sand Cetnta[ Dark ml: 17 gal water D Bentonite Pellets <br />❑ 9entooite (20% solids) D !danufachaer Spec % solids _ % Now D Specs on File C3 Specs Submitted <br />Placement Method Cl Pumped ❑ Free Fall D Other <br />t �orn� ❑ Co lets with idtlshtoom C ft below goad^, D Complete m Existing Surface Pad <br />.. =v.. n..v snail Ire WURA WILL BE DOVE IYACCORDANCE WITS SLAV <br />NJAQULN COUNTY O rA- CES, STATE LAWS, AND RULES AND RMULATDONS, I ALSO CERTDFY TRAT 11Y REQUDRBD LDCENSE is <br />CURREd'T AN AC7 1 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I A31 LY COMrLINCE WTra ALL <br />WORYBRS C 1 <br />97TLL_ DATE_L1__(G/�.� <br />� RF�FM4�0� <br />h F�7O QUA 1% <br />')OF4MF,COU <br />Applicmiost Accepted By �{� JLC D q Employee 11, <br />Grin InspectionBy Date PECL►I. Well Permit <br />pumpDaae, cction sv__ Dam _ I D WAIVERReceived <br />Destruction tnSocciior. 97' _--_- Dz*a _._ Constructed Well Depth <br />9/11/2087 <br />:i'O Permit and tkeheadem.dru <br />