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<br />4$S8 East Hazelton All".wn-STOCKTON CA 9620$- 21.2 . 1,209' 480.3420
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<br />4fe Nr eaci Z { (AQj)er TPr-o a 20P, 652-5009
<br />1r,MUCTOR AODPz.,-z 646 u: 'California Street
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<br />NNSF.0 C -moi �D Other
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<br />Coordlnaters X y
<br />CITY/STATS/ZIP
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<br />C1Ty/3iATE1ziP__. _ _ JQ -ockt on, SCA � 720,,,
<br />CITYI.°iS A7ZIZIP
<br />EXPIRAT10N DATE 08
<br />_ Township _ Range Saction
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<br />0 Puptic 0ter ]ta2lft Mo ,t S
<br />Wstcv §wtem
<br />if 6,70” ftr„ Wale.
<br />HN2 C ti'OW +Atn,! C Raplawmlen! wel! 0 Well AJterationNodiflcation
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<br />put-Of-S".rvfcQ Well R#arew 0 Cross-COnnoction Repro r
<br />C hety Pmc _ M p Fur•,a Realacerr�nt f?�{np Rropsir
<br />ill!ng Mathoe D t!uc ?otrry ^ Air C':ol*ry Q Auger C Cable 7o-,, 0 Pus:., point 0 Other
<br />oposad'.q'^!I 0e,-r._Mit wXclivat"O., In dinraotor ;C Open Bottom p Gravei PacldGravol Size' •'. T '
<br />Clanduc:or casing.r! +w
<br />_,.,,,.,.� in ,, ame ^r 1 Conductor Gaslnw pc,pm
<br />VJsI! Cnalnp In Thlcicness/GaugeiA.STIA ^sohad t7 ?ter; 0 Pi r!
<br />Oro, --t ,y 9btIC G 4't6t 4DG uteri q Qther_,
<br />Snct Grrp - ..__.�._,t ^ Moat Content !94 tb P&O -10 :'al tvn S —
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<br />�etgrdant/Accelorator(name) y
<br />yrs_ InsMiled By u Dritle. C+ Pump, Conkracta Hp Other
<br />^,,,�,�� Q Canc;ete Pedc:ets{ Rtms:,ston t'�r h`"
<br />6. iCth
<br />F Thio+: e. ir, D ChristtY $ox ' Stove r� tae
<br />Turbine 0 O's _ HP w::mp $& j� y it St �nding`yNr lkr Leva ��
<br />i�.RCG `' CCR I -Y -. j -A" I HAVC PRBPARED THIS APPLICA,10N, Akio THAT THS V+1ORK WILL SE DANE !N ACCORDANCE a'11TH 3Ai, ! '
<br />:AQI:I� COt/Ti'.I" ORDINAINCIrS, 37ATE LAWS, ANrd MULES AND f EGULAT ONS. I ALSO CERTIFY TPAT I`AY RLr"JR0- L :�tWBE ;S
<br />.IRRLN T A.ND r%CTIVt +�'/!Tk TH1 CAUFORNfA COtt YR ACTOU STATC LXENSI? DOARD AND ''t�AT ,! f r IN c01lj!�L!ANCS Y`r""!•f At....
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<br />,r � a 9 _
<br />Application Accepted By
<br />Grout Inspection By
<br />Pump Inspection By
<br />Soil Boring Inspection By
<br />COMMENTS
<br />)E ARTMENT U E 9NLY
<br />Date (2-1d�
<br />Date
<br />' 'Date
<br />Date
<br />Areae_ Employee ID#ANMI
<br />P
<br />SPECIAL Well Permit
<br />WAIVER Received
<br />Constructed Well Depth ft
<br />PE
<br />Codes
<br />SC
<br />Info
<br />Recelved
<br />B
<br />as
<br />Amount Permit/
<br />Remitted Date Service Request #
<br />-
<br />Invoice # well ID#
<br />i�;°
<br />ZAK
<br />3/� (6,T
<br />77 9- vj P00 5971e.3
<br />EHO 43-06
<br />8/04/08 WELL /PUMP PERMIT
<br />
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