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SAN JOAQUIN COUNII'ENVIRONMENTAL HEALTH DEPARTMENE V 384E WEBER AYE 3"rL-STOCATON CA 95202 -(209)4"-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED to JOB ADDRESS rJN L✓' /JY'' CIT'/ZIP t ^ 1 CROSS STREET 'r iv' �+vi a APN G-C,'�'� I 'f (% L-4• PARC/ /�jE�L SIZE ` ✓� LOWNERNAME TL/J'I'1 >L'"Q�e¢{/.Y PuoNE -1(f.7(0— 5liciL OWNERADDRESS CrFY/STATVZIP/, ✓+ CONTRACTOR �"C/L/��/ C/JYaC/�S{JJr�CyA/,F]£�/e*�/Jv-o->� ;'Q PHONE .�J � Z O V- ,/l CONTtACTORADI RESS Ls5N,1,L' 7�Qd �//��7C/3 / CITY/STATEJZIP �%f+' SUBCONTRACTOR PuONE ^ SUBCONTRACTOR ADDRESS Crrv)SUTTEMIP p� 1 ! LICENSE El C-57 El C-61 in D-09 Ner Z NUMBER �J'r°/' EXPIRATIQNDATE � >:� GEOGMPNICAL INPORMATON: Coordinates X Y Township Range_ Section_ erg INTENDED USE esoiJPdvam ❑InnipoioNAgriculwal Otndistdal ❑Water Quality Monitoring mm O Soil SamplingrChnmeterivdon T Cl Public WriterSysrem If EiRerm,lmm Ow�ve er vomer Pion,N,raw� TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alm iu.nrModiOcation ❑Tat Hole ❑Other ❑Monitonng Well(s) nnm6crnfwde C3 Soil Bonng(s) nvnmarorwnno ❑Geotechnical ^^^�erendny, L ❑Well Desuumon ❑Ow-Of-Service Well ❑Om-Of-Smite Well Renewal ❑New Pu pnrp Re,lancentem ❑Pump Repair ❑Cross-Connemlon Repair WELL CONSTIJuMON Drilling Method ❑Mud linty ❑Air Rotary ❑Auger Cl Cable Tool ❑Push Point OOther Proposed Well Depth fi Excavation in diameter ❑Open Bottom ❑Grivel Pack/Gravel Size in diamntt j ❑Conductor Casing in diameter / Conductor Casing Depm It T well Casing Diameter_in Thickness/GaugieASTM Schell ❑Steel ❑Plastic ❑Scaulasx Steel ❑Other Grout Seal Depth R ❑Neer Cement(94/h bag/5-10yw/wore,) ❑Sand Cement ,.,Arum/7gal wale, • ❑Benwnite(20%solids) ❑Manuhcturer Spec%solids_% Name ❑Specson File OSpas Submined 7i r Grour Phcemenl Method ❑Pumprd ❑Free F"II ❑Other ❑Rwrdant/Aecdcan r Imme) _ has PEDESTAL Installed BY O Driller ❑Pump Commuter ❑Other ❑Concrete Pedesbl Dimensions: Width_ It Length_fi Thick in ❑Christer Boa 1:3 Stove Pipe Pump �39ubmmiblc ❑Turbine OOthtt HP J Pump Stt /AL2 Standing Water Lovel � fi WELL DMRUCTION ❑Open Bottom ❑Gravel Pack ❑Untaxed ❑Other Ilia Well Diameter in Tonal Depth 0 Depth W Wenn it ❑Casing to be Perforated from_ft to_ft Scaling Material ❑Neat Cement(941A hog/3-10go1 werar) ❑Send Cement ancA anis/7 gal wooer 0 Bentonite Pellets ❑Bentonite(20%solids) ❑Manufaeourn Spec%solids_% Name ❑Specs on File ❑Spees Submined Placemenl Method ❑Pumped Cl Fra Fall ❑Other , ❑Complete widi Mushroom Cap 0 below grade ❑Complete to Existing Sud'ace Pad r I HEREBY CERTIFY THATRDIN I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL IF DONE IN ACCORDANCE WITH SAN CURRENT N COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS SPATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMM JiS T / MINIMUM 24 HOUR ADVANCE NOTIC/�-REQ IRED FOR INSPECTIONS 7 G3 r y�j rl --ri� '(� — SIGNED TITLE {� DATE LECE f 7A AM A 1 ---/-�' PARTMENT USE ONLY, Application Acceyred By Zrl_'t1 ` �.( - /�'-'�`F' DMe (`��5 �~� Area - 2 N Employee IDM lqJ i^ 1(` Groin Inspection By Date 13SPECIAL Well Permit Pump Inspection ely Dote ❑ WAIVER Received Ocawcnon Inspection By Dene // ,, Constructed Well Depth it COMMENTS his, PE SC Amount Ch." Received Permit/ Code" Loots Remined vso BY DYte Service Re near IN InvoimX Well IDX EHD 43.62-086 MASTER W At'ER WELL PERMIT 577_06 r