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FOR DEPZ-.0FZ7 PerrVtt"ITo <br /> mate., = Wup - f STANISLAUS.COUNTY <br /> Date Issued <br /> DEPARTMENT OF€-tIMMAONMENTAL.RESOURCES <br /> 1716 Morgan Road, Modesto, CA 95351 <br /> (209) 526-6892 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Stan islaus County Department of Environmental Resources fora permit <br /> to construct and/or install the work herein described. PLEASE NOTIFY THIS DEPARTMENT (USING <br /> PERMIT #) WHEN WELL AND/OR PUMP WORK IS COMPLETED. <br /> JOB ADDRESS/LOCATION ' "- -City <br /> Owner's Name.. �f�e r�..r. P. r t_4 - , Phone - VZ,,z?gZ <br /> Address � fi 1 �'? � ' !.: ds City/State _ a 4,0 cam _ <br /> Contractor's Name _, �_ License # Phone <br /> TYPE NEW WELL . DEEPEN ❑ RECONDITION ❑ DESTRUCTION ❑ <br /> OF (CHECK): PUMP INSTALLATION_ (NEW WELL) ❑ PUMP REPAIR ❑ PUMP REPLACEMENT ❑W' <br /> WORK OTHER <br /> DISTANCE SEPTIC TANK SEWER LINES` PIT PRIVY {n <br /> TO NEAREST: OTHER WELL SEWAGE DISPOSAL FIELD* CESSPOOUSEEPAGE PIT' <br /> OTHER �1 <br /> INTENDED USE TYPE OF WELL' CONSTRUCTION'SPECIFICATIONS <br /> ❑ Industrial ❑ Cable Tool Dia. of Well Excavation /y <br /> Domestic/private ❑ Drilled Dia: of Well Casing Ir.X .ore-, W <br /> Gauge of Casing w <br /> ❑ Domestic/public ❑ Driven Depth of Grout Seat <br /> ❑ Irrigation . r�.�+Gravel Pack Type of Grout <br /> ❑ Other L�7 Rotary Other Informations r <br /> raOtAd <br /> ❑ Other <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work to be Done <br /> ?UMP REPAIR:' ❑ State Work to be Done <br /> :)LSTRUCTION OF WELL: Well Diameter Approx. Depth <br /> Describe Material and Procedure: " <br /> 'LOT PLAN: Show on reverse side. <br /> -OR DEPARTMENT <br /> JSE ONLY: Permit Issued by C - Date <br /> Permit Denied by ' (See separate report) <br /> Inspected by Date <br /> WHITE COPY-Applicant YE.1-1.0W COPY PICIK C01", , 011scc <br />