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' SAN JOAQVIN COVNWENVIRONMENTAL HEALTH DEPARTMENT 30d E WEBER AVE 3nn FL-STOCKTO (SII9 20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR UED <br /> �� m <br /> ' 14— Assets,Latest <br /> JOB ADDa[sb `1-I`fin�s y` !®/�VR� � CrtY21P /VC /!� � <br /> /%r e_�J/ APN_Rf/7_ L ___ 9 <br /> CROSS STREETQISAY PARCELSIZE S s <br /> OWNER NAME <br /> �/I ryAl L �yr CA PHONE �J 1 3 ' 1 <br /> OWNERABDRESS p Yy% CrrV/sTATVZIP <br /> CONTACTOR � //J� 6CC i*//lI PNoue37y—y77-.� V <br /> COM'MCrORAODRE(SjS� /� n CITYISTATFJZIP ^G", <br /> ' SUBMWRAMR *�� G- /n'�Y P_HONE����j�C��(0� <br /> SUBCONTRACTORADDRE65 ! r CITY/STA7LZIP <br /> LICENSE C.57 0 C-61 0 D-09 0Other Numem SS EXPIRATION DATE <br /> ' GEOOMMICALINFOtIMATION: Castroism" X Y Township_ Range_ Section___ <br /> INTENDED USE —'AiXDomM[iUPdvam 171mgnrionlAgricalwrel 0 indumdal O Water Quality Monitoring 0 Soil Sampllng(ChaMemrRmion <br /> 0 Public Water SYstw <br /> ItROaeal Rem ou: aw Starts ame anmD N..Mt. um <br /> ' TYPE OF WORK.)<Nm Well 13 Replacement Well O Well AIterstimJModiflonion 13Test Hale C3 Other <br /> O MuDitoring Well(S)__ numon.of. is numaa nrkvnntp OGeotcehnical -saa-rmrina <br /> O Soil Borings) <br /> O Well Destruction 13 Out-Of-Service Well ❑Out-0f-Service Well Reruwal <br /> jjN;,Pum Opens,11cphommel 0 Pump Repair a Cmes-Consectien Repair <br /> ' WELLCONSTRU — <br /> DriWelgMelbodMudAotary DAlr Rotary OAuger 13 Cable Tool ❑Push Point ❑Other <br /> Proposed Wall Depth _R Excavation in diameter 0 Open Bottom .4Gmve1 Pass?Gravel Sitt in diameter <br /> Cl Coducmr(hsing in diamcmr J Cordacwr OWN Depth A <br /> ' Weil Casing Diamr,�in Thieknees/CwugNASTM Schell 0 Steel .hPlauic 0 Stainless Steri 0 Other <br /> Grant Seal Depth q=10 ft n KNear Cemam(94lbbag/S-Jdg,u1.1.) PWid Cement � sark..17 gal wattr <br /> 0 Beretta(20%solids) 0 Manufacturer Spec%solids % Net . ❑Specs on Filc 0 Specs Submitted <br /> Crout Placement Matkad jeurnped OFrm Pdl O(Rher. ORmardsot/Attelmatar(rume) <br /> ' FEENWAL Installed H �17riller 0 Pump t.DOlmcrOr 0 Other <br /> O Concrete Pedestal Dimendovs: Width 11 Length a R Thick in OCheisty Box OSIOVEPipe <br /> PUMP .,4 . a nersible 137WINne DOther Hp__5 _ pump Sel fl Standing Wath Level R <br /> WRLI.DPSFRUCTION ❑Open Bottom O Gra el Pock D Unwed C!Other <br /> ' Well Diemeter_m Total Depth D Otto w Water fl OCasing as be Perfumed Rom_R to__it <br /> Sealing Material C3 Nes,Cement(94 lb brrg/5-10 gal usaw) C!Send Cement wdlnis 17 gal wale[ Cl Sentanite pellets <br /> 0 Samomw(2G%solids) OMmukcmrer Spec%solids_% Nam. OSpecson File OSpell Submipd <br /> PlReement Method 0 Pumped 0 Free Pall - O Other <br /> 0 Complete wiw Mushroom Call ft below grade 0 Complete w Existing SulRee Pad <br /> ' 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE Cr, DATE 2-r s o ?- <br /> 1 <br /> 1 <br /> 1 <br /> ' DEPARTMENTU ON <br /> Application Accepted BY Dale `7 0 L Arca '2-12— Employee IDB Yv yr <br /> Grow I.psction By Dare z ❑ SPECIAL Well Permit <br /> ' Pump inspection By Dau 1 —02, ❑ WAIVER Recelved <br /> Destruction Inspection By Dam Constructed Well Depth R <br /> COMMENTS- 0 s <br /> ' 02 ot cYC <br /> PE SC Aotla Revolved Date PcrmlU Invoke# Well[DO <br /> Codes Into Remitted B Servie<R tact[# <br /> �,� a' <br /> 38'0 Drs / m©3053 t6f�,Llct r <br /> ' END 43-02-006 MABTFA WATER WELL PERMIT <br /> 517002 <br />