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0581 •IN WdWE L106 '0[ 'lnr moil paA ! ;D;t <br /> r • ; <br /> WELL/PUMP PERMIT <br /> SMI JoAcuri Coum7YEyV7RON1%1EPITAL He.AL7m DEPARTMENT 1668 EAsTHAZELTa i AVENUE-STOCKTON CA95205-(209)4683420 <br /> PEON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeAoaRE8s2527 S JackTone Rd cITTmP Stockton CA 95212 il <br /> CROSS STREET Farmington R d APN 0 PARCEL SIZELAND USE APPLmATIoN d a <br /> m <br /> OWNER NAME Jan Weber PkoNE 209-405-0215 <br /> OMIER ADDRESS P.O . Box 1042 c„Y/sTA,,jz, Linden Ca 95236 <br /> COP,MACTOR P�urviance Drillers, Inc. PHONE 209-887—X35^54 <br /> CONTRACTOR T <br /> ADDRESS C. 0. pSox 64 CTry/s•rATFJZjP T-inde , <br /> nC`1 :7573 <br /> SuecoPnAACTOR PHONE <br /> SusconTRACfoR ADDREss CITV1STATFMP <br /> LICENSE •_C-57 _C-61 D-03 s other NuNOER 3 7 7 9 2 3 ExpmATtoN DATE 7/31 /17 <br /> GZ-OGRAPHtCALIN1;ORMA-nO1i_ Coordinates X Y Township_ Range Section <br /> INTENDEOUSE %DomesSUPrlvate -'IrigationAg(icultucal _Industrial 1-WaterCluafilyMonitoring Sol Sampling/Characterization l <br /> Public Water System <br /> IrmlFerenl from Ovmen ater rs m amctxfdad.N.fha or PrIolin N.Fhbet1 <br /> I; <br /> TYPE OF WORK NewlNeli _Replacement Wet _;WeII AlteratioNt/odifiralion _Other <br /> MonitodngWelt(s) Tofvrells cl SODBoringts) aol00natis -Geotechnical softwdngs <br /> i Out-01Serviee Uvell -Oul-OFService Wev Renewal ^Goss-ConnecCon Repair <br /> C PlewPurnp 0 Pwnp Replacement C•Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method a MudRolary _Air Rosary Auger Cab le Tool _Push Point Other <br /> ((Proposed Well Depth R Excavation in diameter Open Bottom -Cdevd Pada/Gravel Site r diameter i <br /> { i ConeuctorCasing Indiameler I Conductor Casing Depth R <br /> lilili Well Casing Diameler_in ThidmesslGao WASTM Scheel C Steel _Plastic 7 Stainless Steel --Other <br /> Grout Seal Dapth ft J Neal Cement 1941b baa(5-10 gal watet) Sano Cement Sack mW7 gal water <br /> Bentonite(20%solids) ,.Other <br /> lGroutPlacementMethod =Pumped Free Fall =Other RetardardIAccelerator(in alne) i <br /> PEDGSTAL Installed By -:Driller -Pump Contractor = Other <br /> Concrete Pedestal--Dimensions.,Width 11 Length ft Thiel: in u Christy Boz _Steve Pipe <br /> P Sulxnersibleu Turbine Other HP Pump Set ft Standing Water Level O it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION A1,JD TAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> T�MPEN OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> TrrLE Corporate Secretor 7-`o-1-7 <br /> ' � I <br /> I ! + <br /> pPyMNE° , I � 1 <br /> �►°oN <br /> • s,a+��oEP IE iO. s <br /> H <br /> EP TMENT U E NLYAll <br /> Application Accepted By ate 0 Ar--B 1-1- 1_- 5mplayee tDk_�s.d�+l t O <br /> Grout Inspection By Date O SPECUIL Well Permit <br /> Pump Inspection By Date 1 i q 11 UVAIvER Received <br /> Soil Boring Inspection By Dale 1� Constructed Well Depth ft <br /> CO]'"ENTS <br /> PE SC Received Check Amount Permit/ <br /> Codes Into B Cash R=MLd Date Service Re uest r Invoice Well FD# <br /> 0!90 6c-- —7 U 0 3(� D3 <br /> I <br /> EM d3� '1/r'1�PUMP PERP.R <br /> +n3n2 U /T <br /> Z'd 'Z9CL9960Z oul siellu4 aouelnand e0t,:0 L L 06 Int <br />