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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARWENI'LL/PUMP PERMIT <br /> 304E WEBER AVE 3"FL-STOCXTON CA 95202 - (M)469-3420 <br /> NON-REFUNDABLE <br /> PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JODADURESS if.l.�BJ 5 }�/f / �� L. <br /> CROW STREET APN_ Z Z�pI I <br /> It,-e, PARCEL 512¢ 7 D <br /> I / <br /> • OWNCRNAMC _7ocik <br /> 'TPuoaE—p69 , <br /> S <br /> OWERADDRE2 ( <br /> 4 CmISI•ATEFLIP��A <br /> Cowm[TOR <br /> / �,r� f- PHONE <br /> CONTWCTORADDRESe��� (e/ may/ > CITV/SYATiII.IP r��S366 <br /> SUBCONTRACTOR <br /> PROVE <br /> SUBCONTRACTOR ADORYSS <br /> CT'/$YATF.lLIP <br /> LIeeNSE ❑C-57 ❑Cfil O D-09 ❑Other, e—47 :NUMBER I(A <br /> _I <br /> GEOGRAPHICALINFORMATION: Coprdinnles % _ EXPIRATION DATC!� <br /> Township Range__ Sectbn <br /> INTENDW USE �rlfomcstic/privvte ❑IrrigatioWAgdculluml O Industrial <br /> ❑waterQalily Monironeg ❑Soil SamPRnglche-'H:alion S <br /> ❑Public Wem Syyclem <br /> I(tlimreni rmm Gv, aur rrirm.amt —Za-ik�— <br /> TYPEOFWOR% ❑New Well ❑Replacemonr Well 13 Well Aheruion/Modification OTest Hole 13(M., <br /> 13 Monitoring Well(.)_ w uel.f—fs numeerolbodnlP <br /> .......-_ 13 Soil Buring(s1_ ❑Grotahnical numinr vrhoanlP <br /> OWe11 DesWctian ❑OubOFService Well ❑Ow-Of-Servirx'Nell Renewal 1 <br /> O New Pum m Reelacement ❑Pump Rea' ❑C L colon Repair Al <br /> F <br /> CONRfRUCOGN �L <br /> g Method ❑Mud Rmary ❑Air Ronry ❑Auger ❑Cable Tool ❑Push Point: ❑Other <br /> osed Well Deth 11Ecay.tinn in diamuer ❑Open Bmmm ❑Cuavel PocktGnvel Sitt (n diemetc❑Conductor Cuing in dameta / ContlamrCHinKDepth _it <br /> ll Casing Diamner in Thick hc'/GaugdASTMSchcd ❑SarOPleslic ❑SMinles.Steel ❑Other <br /> romSeal Deplk N ❑NeuCemcnu f94lhhug/5-70 lworrrKu ) ❑Send Cement srn#Mix l7 al wafer <br /> ❑Benronile(2D%solids) ❑Manulecnm Spee%solids Y. NamePbttmeal M<thoIt ❑Pum ❑F Spas on File 13 Specs Submitted <br /> Psd a Fll ❑Reunhutt I Aecdenmr(came) <br /> TAL Installed By 0Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dinneen Y; Width__ D Length__R Thick <br /> PUMP m ❑Ghelay B0Y ❑$t0ye Npp <br /> )n,,Submenible ❑Turbine OOthm NP�_ Pump Sa,�4 It SmMing Wafer Level / H <br /> Wsu,DESTRUCf10N ❑Open Btmom ❑Gravel Pack ❑Uncasd ❑Other <br /> Well Diememr___in Tobl Depth_ A Depth w Water D O Casing n br PeTbrau d Imm_R to_R <br /> Sev%ng Material ❑Nat Cement Na fhhug/5-10Ku/wrrm) <br /> 13 Send Ceres, su<trrtis/7galwata Clan monize Pelkzs <br /> ❑BempZI Pnue%sdida) ❑Free Fell mr Spec%solids <br /> =_% Name__ ❑Specs on File ❑Spas Suheriud <br /> Placement Method ❑Pumped 13 Free Fall ❑Other <br /> Cl Complete with Mushroom Chip, nbelow grade ❑ComPlae TO EvisOng SuMea PoO <br /> ( HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND l'HAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION .AWS. <br /> F--- <br /> SIGNED NIMUM 24 HOUR ADVANCE NOTICE REEOUIRED FOR INSPECTIONS - <br /> TITLE )4e. C�pe D"E <br /> S"/Ii-0L <br /> r <br /> n <br /> DEPARTMENT USE ON V <br /> Application Accepted By <br /> Oak C-Z Area Z f EmalDya IDN%7 /Y <br /> Groin Inspection By Ontt <br /> ❑ SPECIAL Well Permit <br /> pump Inspection By Dale ❑ WAIVER Received <br /> Destruction Inspection B Dow— Constructed WeII Depth_ ft <br /> PE SC Amount Chec Rcaived _.....-PerorV _... <br /> Codes [of. Remitted seh BY Dale SerA R ware Invoice% Well lm <br /> EHD4)-02-DO6 <br /> snn_Do± MASTER WATER WELL PERMIT <br />