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'--vvr,>L,L. / ruivie PERMIT � <br /> 1n\,I(Lt(j(IN COUN'I'1 E\t'IRl)N'tIE\'Itl.Ht:nla7i Dha'AHi-HI t:N'1' 304 E WEBER AVE 31t'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLL PERINII I CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> }} Qjyf <br /> IJOIIADDR}SS � 5� :3. 14 -c 1J d uc, CITY/ZIP Esc do ~ <br /> — a <br /> l l v <br /> CROSS SIRLFI A APN C FARCF-LSIZE LAND USE APPLICATION# M <br /> 0%,Nt:RIN'.Aa1t: vidlli - t? 1tZ1 �rr� PFIONE <br /> Osvnh:RAuuul.tis 18353- �. garrol [nuc. <br /> CITYISTATEIZIP <br /> �S��tIOr� <br /> CO%I'RA( IOR tRvlan.e-In- Jt,(IItYs 1I)C PHONE <br /> CO\TRACTOR ADIIIRF.ss CITYISTATEIZIP <br /> A y� <br /> Sl'R(ON-I RA("IOR N�r,T- - PHONE <br /> f <br /> SUIR ON I RACI OR AIIIIRF.SS - - �� y CITYISTATEIZIP <br /> }f <br /> LII F:\SF: IffC•-57 OU-61 0E)-f19 ❑OIhc'I' NIJMBt:R 37712-3 EXP[RATIONDATE L� �'Q6 <br /> I <br /> (: KMAJ'IntII <br /> rA1\ 4tuntAION: ['unrdinutet S � - — N' Township Range Section <br /> INII Not.[)list I>„mcsl1�':'i'r1�a1a ❑ Irrrr:rliori AgrlcullwA ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactcri[ation <br /> ❑Public �kolcr Sy.acnr <br /> Ifdill rn,i G,,r,,(r'snrr Contact Nameor Phone Number <br /> Tt Ilk:OF;NN'ORK ❑Neµ Wcll ❑ Rc!placenlcnl �kell I]NN'e]I Alteration/Modification ❑Test Hole ❑Other <br /> p of borings a of borings <br /> ❑M1lonitnnng 1l'clilsl —_�nl��cclls 71Si4zl Boring(s) ElGCoteChnIC81 <br /> ❑Wt'll DclUlwilon ❑Uut-Of-SCYICC Well ❑Out-Of-Service Well Renewal <br /> ❑Ncn'Pump ❑1`1111111 Ru lacenunl If Pump kcpair ❑Cross-Connection Repair <br /> 1N`ha.l.CONSTRI'("riON <br /> Drilling Melhod ❑Mud Rolm, ❑Air Rolary ❑Auger ❑Cable Too] ❑Push Point ❑Other <br /> Prnp[ISed %Nell Depth _ _ _-__, Il I�Xcavation --di diameter ❑Open Bottom ❑Grave]Pack/Grave]Size in diameter <br /> ❑Condurtur Cd.vng rn diameter C'onduclor Casing Depth ft <br /> «'ell Casing; Diameter m T}4icl t}cs,;(,augc ASTM Schcd ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Scal Depth it ❑tical[Cement(94!h water) ❑Sand Cement .rack mix/7 gal water <br /> ❑ Hcntonilc I?ll'',-;❑tidal ❑ tiper xllids % Namc ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑ Free Fall C7 Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contracuir ❑Other <br /> ❑Concrete Pedestal Dimensions: Width Il Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> Pt,\IP ❑Suhmersihle ❑Turhinc ❑Other lip Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, ti'I'ATE LANNS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACI'l-L NN'I'lH THE CALIFORNIA COWS'I'RAC-IORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> NtiORKERS COMPENSATION LAN%S. <br /> ~ hINIi�1Uti1 24 HOUR ADVANCE NOTICE REQiJIRR INSPECTIONS <br /> .�- <br /> ---- ----- ------ TI I I,E DATE I a 4 0 <br /> All <br /> 1� <br /> I 2� J � <br /> r a� <br /> 1= r= <br /> , <br /> U JTJ <br /> H L <br /> DN RT .NI E INT U S �ON Y <br /> Applicannn Acccpicd Hy � '� _ Date_ Area Employee ID# /sG <br /> (iruul Inspection 13y _ - _ Dale ❑ SPECIAL Well Permit <br /> Puntp lnspcclinn Hv — _- Dale. v 11 WAIVER Received <br /> Oesuucuon Inspection 13y Date Constructed Well Depth ft <br /> PF. SC Received Check#/ Amount Date Permit/ Invoice# Well iD# <br /> Codcs Info By Cash Renlitied Service Re uest# <br /> �l� -1134 6, 1a ylo '2 0 v <br /> }hill-n n�nN tl'F.I 1 rl'MP PFR"I <br />