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WELL / PUMP PERMIT <br /> SAN JOAQUIN CHUME ENP01bNMEAT,V,1IeAL . - PARmmrr• #12711 600E. Malo Surtu - SiA- . .JNCA95201 - (209) 468-7420 <br /> li NON-REFuNDABLEPERMrp CALL 209 9574697 FOR INSPECTIONS EXPMES I YEAR FROM DATE ISSUED <br /> JoBADmEgEr 2454 Country Club Blvd . CtT IZIP Stockton 95204 g <br /> aeosssmerr I 5 APN_123-040-07. PARDO•SZL Q • S LAxo Use AaeuunaNY <br /> OWNER NAtAT William Wilson PRONE 451-4427 I <br /> OwNERADDRESS same CrtyISfATVI.v <br /> CONTRAcoR Delta Pump PuoNE209-466-9625 <br /> CONTRAcrORAmmEE; 646 S . California Street CIv/srATuzv_ Stockton . CA 95203 <br /> BDBCONrRACrDR PRONE <br /> SUSCONTRACTORADDRESS CITY/S1'ATFII•R <br /> LICENsE 13C-57 XXC61 OD-09 0Other Nsamur 724778 ExrouTroNDAn 08/12., <br /> GEOGRAPBer:ALINPORAfAItONt Coordinates X V Towesblp_ Range _ Salloo_ <br /> INTErmEOUse x5dOomeNaprivac Cl brigedoNAgriculmnl .- Olnduetrhl - O Water Quality Monitoring O Soil Sampiing/GDaneNrnliov ifv <br /> ❑ Public Water Byyskm <br /> Ir4Df Gem Aroc nv Yarm we oomm amaw <br /> TYITOEWORK ONcw Weil O Replacement Well O Well AlmrstiaNModificallon DOthef �V I <br /> [] Monitoring Well(s) Y orwells Cl Soil Borings) Yof6micn 0GeolecMical aorbadngs <br /> [] Out-Of-Service Weil 0Out-Of4ervlce Well Renews! OCtoss-Connection Repair <br /> [] New Pum )C[Pump Re lace rnma 0 Pump Repair <br /> WE - ONS rnUN ((( <br /> Drilling Method [] Mud Rotary [] AD Aotery [] Augur QGNa Tool 0 PVsh Point Cl Met �\) <br /> Prepared Well Depl4 ft EzeaveRan tadlsmeler [] Open Bottom 0Gravel Pack/ Gave] Size in dluvcter <br /> ClCooduclorCaslag tadismeter / Conductor Casing Depth R <br /> Wall Culag Dismetm _m Thiekvese/Geugc/ASTMSehed [] Steel OPlastle O Stainless Steel Clmcr <br /> Grout Seal Deplh A ONeat Cement (Y41b bagI540gal watt) DSend Camont sock mgr 17 gal water y� <br /> O Benmoim (20% solids) OMenuPoemrcr Spw % solids _ % Nemo [] Specson File OSpees Submitted ' 71 <br /> Grant Placement Method CIPurnpul [] Free pall ❑ Other OResudem / Aeeelemmr (nsma) N(. <br /> P&P&FTAL lastalled By [] Driller gPump Contractor O ONu <br /> • OCaoerete Pedestal Dlmeodour Width ft Len ftThick in [] Christy Boz [] Stovepipe <br /> YnR Kl Submerble OTLrbina OOlher HP 1 purap Set Htsmanding Watu Level 11 ft <br /> I HERESY CERTIFY THAT I HAVE PREPARED TIM APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS G <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATE <br /> "`IflINIMU - "24 HOUR A6i ANCE NOTICE"REQUIRED FOR INSPECTIONS <br /> SICNE9 THLE CEO DATR 11 /30/ 10 'w <br /> c <br /> i <br /> i <br /> I� <br /> CI I <br /> L1 <br /> N " <br /> i <br /> O E PA RlkMeENT U E ONLY <br /> Appiv alion Accepted By Date EmploynelDit <br /> Grout inspection By Date / � ❑ SPECIALWell Permit <br /> Pump lnspwtianB G Date ❑ " WAIVER Received ` <br /> Constructed Well Depth a ' / V <br /> COMMENTS ;%, /T,�! y.��7Z r�1J5P� " �l/a t S�r/te=�i� rr i a�trYGF�r�'lucs � eflc,' Az2 <br /> PE SC Received CAmount Dale Perm1U IovalceY Well W4 <br /> Codes In B ash Remitted 9ervim Ar uestq <br /> v cfc o 0 3%L001y/lo/ L WPO O <br />