Laserfiche WebLink
0 <br /> WELL/PUMP PERMIT <br /> ,'A"dAoulN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304E WEBER AVET°'FL-STOCKTON CA 95202-(109)468-3430 <br /> NON-REFUNOARLE PERMIT CALL 209 951.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> n <br /> FARv..-, .--ne-- /_Gl//SE fF-UFiVU.� oTY21r / ei-rs/n/iia 9_$_S.3U r <br /> R 22 rte' / (yJ /�� <br /> �'^�/A-� APN ��1'— 2-(L PARCEL$IZE/�� PPHONEL/ �f�(�� � , CrrY/STATOZIP /G //// rLi "/ k/7-0F55 AM W Z-7e,76 <br /> /1/ /1/11/ PIIONET(0i]012 / CITY/STATFZl'npbaess <br /> - " .r.'FGL TFLF/I/DLOGy n <br /> S ^• <br /> uecoxrxAcroa v # �A a PROBE <br /> ntlrC �� 9.JGZS <br /> Cr1Y/$TATTILIP <br /> .bUBCONTM�OR AnDRE55 /' yy// /ZOOC/ <br /> LwY•rfL^C' <br /> NUMBER VY15(a0 EXPIRATION DATE / <br /> LICENSE -P(C-59 ,6(cfil 0D-09 ❑Omer <br /> Y Langa s«tion 3S <br /> GEOGRAPRICALINFORMATION: Coordinates X J R <br /> Township m Ln Chaenanom. <br /> INTENDED Use 0Domelic/rrivote O lrrigalionfAgricullual ❑Industrial ❑Wemr Qual.1 Monitoring ❑Sail Sa p' g/ nCl <br /> 0P bli Witter Sgcr' r rrwm °rax mmn vm.m ne r <br /> ITdrfe ha 0.. . °12- <br /> TYPEOPWORN 0NEW Well ❑R111.1ansi Well OWell AhmtiONModihcation 0 Test�....fBuo ale ❑Other n.mbe.arro�tnp <br /> wwtuear-11, OSoil Boring(s)__ ❑Geoechnical__ <br /> p Monitoring Well(-)_ El Out-Of-Smice Well Renewal <br /> BhWIWell Destruction ❑Om-Of-Service Well <br /> EEL New Pum ❑Pum Re lacement ❑rum Re eir <br /> ❑Crass-Connection Re Bir <br /> RUCTION <br /> U Cable Tool ❑roan Point OOlha <br /> hod ❑Mud Roury ❑Air Raury OAUBer in diameter <br /> ell Depth 11 Excavation in diameter ❑Open Honour ❑Gmvd Packl Gravel She. <br /> in <br /> Conductor Casing <br /> indiameter / Conductor Casing Depth It <br /> ❑Sled 0 plastic 0 Stainless Sleel 0 Omer <br /> ring Diameter_in ThicknssNGaugNASTM Schur 0$and Cement oak ash:17 gal Water <br /> Seal Uepm R ❑Ncas Cement(91/AIw1y5-lBgut tuned OSID,sonpile OSpms Submuted <br /> O Dentonile(20°G solids) O Manufacturer Spec%solids_% Name <br /> ❑Retardant/Accelerator(nantel <br /> ment Mel hod 0 Pumped ❑Frec Fell ❑Om<r ❑Other 0 Duller ❑Pump Comrsmor in ❑Christy Baa ❑Stove Pipe <br /> Pedestal Ilmeminmu Width11 Lcngth_R Thickpump Set__R Standing Water Levelble ❑Turbine ❑OtherNP P0Other❑O Dmlom Gral rte k ❑Un..red RWELLBEETRUCEI 'Parr <br /> Depth10 WMer�It OCnsing to be Perlorelcd l}am IQ R m <br /> Well Diameter�in Total Dept], <br /> al wamr ❑Rcmonite Pdlda <br /> Sealing Material 0 Nem Cement(94 IA hog15-101"1 waled , $and Cemem /0.3 sad mtr l7p 0Speds on File 0$pecs 5ybmined <br /> O Benlonim(ZOY.solids) O Manufacturer Spec,%/solids % Name <br /> Placement Method ped ❑Free Fell Lry Other �roC71C/I'7�/dyv{N W/TN UNE CNA,erxx"S /�bff <br /> Complete oith Mushroom Cap .J Il below grade U Cannons'.m EMrlmg Surbce pad O <br /> 1 HEREOY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> CURRENT AND ACTIVE IM NCES'THE CALF FOPH A CONTRACTORS STATE LICENSE BOARD WS,AND RULES AND REGULATION& I OAND THAT 1 AM N COMCERTIFY THAT MY PLIANCE EW TH ALL <br /> WORKERS COMPENSATION LAWS. <br /> U 411 RADVANCE NOTICE REQUIRED PO INSPECTIONS <br /> / TITLE DATE <br /> SIGNED t <br /> SA J A iH ER CE <br /> DEPARTMENT USED Y Employee lop <br /> . <br /> Data !/'j/ Aree <br /> Application Ac IN B Data [ISPECIAL Well Permit <br /> Grout Inspection By Dam ❑ WAIVER Received <br /> Pump Inspection By Constructed Well Depth ❑ <br /> Destruction l "F II� Q— <br /> COMMENTS y Cil V0 <br /> Chee"? Rettivan Ovm ParmitI InvolttIt Wall IN <br /> PE SC Amount B Servl<c R[ net'N <br /> Cotler Info Remitted •s .3 <br /> MASTER WAl'ER WELL PENMtI' <br /> EIID 43-02-006 <br /> Snpow <br />