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• WELL / PUMP PERMIT I <br />t <br />SAN dOI COUNTY FII HNONMEATAL HEM.TN DEP.aRT.M1:YT 600E i gull\ 5 TREEf - STOCKTON CA 9$1�. • (. �$•30ief <br />RE <br />aOaADDRESS 11SIH 1J 1hctJ� CTINMAP Lo*-� CA -R �O <br />CROSS C M� <br />� CROSS STREET I— �APV`�r"1_/_.:[(:().� � PARCEL SIZE <br />I ��►�T` <br />OWNER NAAIE ViA `U m s ��Ti�M��l/M IIOhE� <br />a <br />ONTERADDRPS.I' ��" •"I,.Sa1 N/a <br />CRYI$1':17EJLIP <br />L. <br />O Conductor Casing in dimmexer I Conductor Casing Depth it <br />Co,., / <br />TRACrDR e�w'�yjrAk1J�3Y� <br />Q Strel ❑ Plastic ❑ Slaidecs Steel G ether { <br />Ptro.E ?�X9- 2, 549 <br />1 <br />CO\TR�CIOR ADDRESS —J�� a \1 U7fIW <br />CIIY1$iATE &P <br />1�7' <br />0 Rctardaat r Acmica ror (come) _ <br />SL/CONTRACTOR <br />a Other <br />PHONE <br />R Thick in a Cbrlsty Bar a Stme Pip <br />SUBCONTRACTOR ADORM <br />CITYiSTATUT,tt <br />_ <br />D ChW 1 <br />1 <br />LICENSE 0 C-57 C-61 C3 D-09 0 Otltcr <br />�lUAafER <br />EXPIR.YTIO\ D.YTE _ 11Z_ <br />gal water DHemoaiu:Pellets <br />GEOGRtPWCALLiF0Rm.%'i0%-. Coordlnstm Y Y <br />Kmme D Specs on rift D Specs Sabmined <br />BUNKO 0Iraga—Agricuhura) 0industrial 0waterOualitymorutonng 13SOSmplingt7hadctcrization <br />WaMr SY#cm _. <br />Ifddter afire: O.a.:. W=S)u .%— Coraaz V-•mc,PImp -vuc tcc <br />TYPE OF WORK D New W.R 0 Replaccrncoa Well O Well AlteratitmModificatiot Q Tat Hole <br />❑ Monitoring WelHs) n�.ltee<wru'31a 0Soil BorinI aommr,.fGCoeCbaieat numYc.aEhaiaS: <br />Well Desttucil D at -0f -S Tvice WaK Cl Out -Of -Sonic; Well Rewwat <br />WELL CONSTRU <br />DrNitaE Ned" O Mud Roreq 0 Au Rouny O Aug x O Cabe Toot D Push Point a Other i <br />Proposed Well Depth ft .Excasvioa in diarncw <br />0 Open Bonom CI Gm,.el Pack; Gravel Siu in dimtetcr i <br />O Conductor Casing in dimmexer I Conductor Casing Depth it <br />Welf Casing Diameter_in Thickness• <br />g Oattga'ASTN Sebed <br />Q Strel ❑ Plastic ❑ Slaidecs Steel G ether { <br />Grout Seal D pth ft 17 Ncat Cancer t9d Ib tang ' S-10gal avers <br />O Sind C; m= tack mtr; 7 gat water <br />D tleraonhc t2(Y%wiidsl 0 Manufac=zr Spec %,olids ".o <br />\arcs D Sp:-rs on vii: D SpdcsSnbmined <br />Graat Piacemeut.fed" CIPturpod ❑ Free Fall 0 Other <br />0 Rctardaat r Acmica ror (come) _ <br />PEDe.ST:1L Q th8t:r O Pump Connector <br />a Other <br />❑ Concrete Pedestal D ismadons: Width It Lcrt _ <br />R Thick in a Cbrlsty Bar a Stme Pip <br />PL?rP aSabinersdbkc CI Turbine ❑Other HP <br />Purap Sp ft St3nding1Yaar Le:c1 ft <br />IVELL Dt'sritucrioN 0 Open 111 D Gmel Pack a vocased <br />D ChW 1 <br />1 <br />Well Diameter` in Toni Depth ft Dcpth to W=r <br />_ ft D Casing to be Perforates fr-w fi to R <br />$tai}nr-1daferial D\eatCemeatrp416bug, 'S-JOgalanrery DSatsdCemtieackat[;!? <br />gal water DHemoaiu:Pellets <br />0 flentooi c i201.i. solids) 13 Manufacturer Spee % solids —% <br />Kmme D Specs on rift D Specs Sabmined <br />rlace ut Method 0 Pumped 0 Free F411 D Other <br />l <br />LD Coniplet.- with Sfushm m Cap ft beiow grad¢ <br />D Complete to Existing Surikce Pad <br />I HEREBY CEP.TtF-' THAT I HAVE PREPARED TINS APPLICATION AND THAT THE WORK IVNIf.I. BE DOVE IN ACCORDANCE WITH SAN <br />JOAQUIN COVN Y ORDINA. S. STATE LOWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQLUED UCL%SE IS <br />CURRENT A.\DAL{TIVF.4"4W CALIFORNIA CONTRACTORS STATE LDCENSE BOARD AND THAT 1,01 LY CONPLIANCE WITB ALL <br />TITLE (iG�%U DATs21 <br />-- -1- - <br />DE, <br />AR?A7E.vT USE <br />Application AcccptedBy.. _. Date / �_ _ :.ria _•emfoy.�!t)::. _(,(� -/ <br />Or.utlnspeciion$)' DalecClil,FVcllpet-t�if 7 <br />Pomp ingccdon By— _ -- .— Date �;L 'i':' ;'aER ReCEIcYf2 p <br />Destruction an_pcc'on By Date 11 C arl.truclec---Sell i?c:,th - ---- u <br />COMMENTS `�i� ; �Se �U Gt)IJ wY wDtlFiCir -- ------._—_-- / RFCPFN�' <br />F� <br />�v<rn.v v.Ln :teiS P4min 2lM'Jer`ardCardu� <br />�4fi <br />