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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL H EALTH DEPARTMENT 304E WEBER AVE T`FL-STOCKTON CA 95202 -(209)46&3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Q i ce JOSADURESS i�.3.S8J /x/4/1- /C� CITYRAP 281AN-Tri-LL • CROSS STREET ./ � ) /'J / APN Z ZtC I I C^3< PARCELSIM . OWNER NAAn: JOCL YC/S d4d,�.,o ) /� �tp1lov'E R'z S.'? A 951 OWNERADDRPES 2 3SSS ✓ ///Qn.7^GG4_T- AW CIIV/STATVZIP //l E ��-95337 CONTRACTOR �A144�.jj5 S�'Y//rJw� �ltl .JiAJC _ PHONE CONTRACTORADDRIdS .7 ({/ 0,5,4, St CITY&rATF/LR 94M'6 . CA 95-3" ,,v'nn � SUBCONTRACTOR PIIONE y SUBEONTRACrORADORIUS CITY/SEATEILIP LICENSE ❑C-57 El C61 0 D-09 ❑Other /^� NUMBER EXPIRATION DATE e/ y GIXeORAPHICAL INFORMATION: Coordinalea % V TOWMMP RaruN_ Bernal_ Imium D USE $DonRniditmate ❑IrriptioulAgdculmral ❑Industrial O Water Quality Monitoring ❑Soil Sampllng/Charaoteriaatien 3 ❑Public Wow Syyclam If oitNm�fmm O.r. .51.14. noun amen u TYPE OF WORK ❑NEW Weil ❑Rcpho meat Well 13 Welt Altera ion/Modification C3 Tea Mole 0Clher .wL ❑Monitoring Wdl(s) wmMofWu 13 Soil Boring(s)_ nuvJW eTh.Nroy ❑Gcotahnial °0"'aFMbadnp 'O ❑Well OoUuctlOn ❑Out.00SeNice Well ❑Out-Of-SeNke Well RexwW ❑New plart, p Reelaccmcnt ❑Pu.p Repair O Cn seCoMmetion Repair WELLCONSTRUCTION DrUllag Method ❑Mud Rotery ❑Air Salary ❑Auger 0 Cook Tool 0 Fush Poin: 0 Other Proposed Well Depth H Excaverion in diameNr 0Open Sonom ❑Gravel Puk/Gmysd Si. in&enKve, rev ❑CotWuclor(hvag in wameter / Coaducar Casing Depth H Well Casing Dismeter_in Tdc1uw&/Gauge/ASTMSched OSIM Opieal. ❑Seainkaa5teel ❑Other Grout Scal Depth H El Neat Cement(Pe/Abag/5-/0,ed sewer) OSend Cement svcR Mia/7 gal web C BentoMte GIN,solids) O Manufacturer Spec%solids_% Name ❑Spees oo Fik ❑Specs SuMnilted Grout Placernent Method OPum,ed OFree Fell OOther ORetardut,t Accelemlor(name) PEDESTAL Insblied By 0Drilkr Opump Consracar DOlher Cl CotI Pedestal Dimendoos: Width It Length it Thict, in OCheisty Boa ❑Stove P,1 Putup XSubmenlble OTurimme OOUw__ HPI` Pum,Set��H Standing Wear lsvtl / H WELL DESTVWKIT1001 ❑Open Senate ❑Grovel Pact, ❑U....d ❑Other Well Dameter_u, Tmei Depth D Depth to Water H 0 Casing m be Perlbmkd from_H to__H • Sealing Mehrial ONut Camrnt(94/h but,/5-l0xu/avdrr) ❑Sand Common_ ..*miF/7 Sal yww ❑fkntotim Pellets 08cntoutc(20%solids) ❑Manujn,u,w Spec%solids % Name ❑Season File ❑Specs Submiped Placement Meshed ❑Pumped ❑I=Fall ❑Other O Complete WBh Must.Cep it Mo.grad. O Complete to Exist Sort.Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION WS. IM UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS O SIGNED TIn.E 04'e &A " DATE a ' r I,IYI Iur 4"o �QDEPARTMENT USE ON Y Application Accepted BY �-L,ae-�(a`— DMc C-7' Arca Z ( Y ElnoloYrn ldl� Grout Inspection By Dale ❑ SPECIAL Well Permit Pumpilupecntn By Date ❑ WAIVER Received Deawuon Imptedlion B Dna Coruncrsed Well Depth it COMMENTS • PE SC Antuunr Cda Received PermlU Codes Info Reorotetl ash By Data ServlceR uvstR Invoiretl Well IDR C ddrop004oSif . EHD43.02-006 MASTER WATER WELL PERMIT $nG w