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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR IMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95.202 -(SW)464'3420 <br /> NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AODRESa zro6 CrrV21P ::qLeN'v&n a <br /> I, 0 <br /> CROSS STREET �)� APN 001-230.43 PARCELSLU— LAND USE APPLICATION 4 _ <br /> 445.3.3 <br /> ONNER NAME l CE N(t/4/L!S/JL T QZ a7 LLCM-S PHONE <br /> OWNER ADDRESS �P{J1 CITUISTATEIZIP <br /> CONTRACTOR ke+�r/ Inc..MPHONE <br /> CONTRACTORADDRES `�- CITVISTA71YZIP f&e-6w-C) <br /> 45 XQr <br /> SUBCOANNUVE'OR S4{NUL I, PHONE <br /> SUBCOMRAc Nr ADDRESS_ CITYISrATOZIP <br /> LICENSE C•57 OC-61 00-09 ❑Other NUMBER N67262 EXNaATIONDATE <br /> GEOGRAPRIGLINFORMATION: Conrdhestes X Y TDwnaklp_ Range_ Section_ <br /> INTENDED USE 13DmumaldPriv81e O lrrigericn/Agricultunl ❑InduHdal O Water Quality Moniroring Soil Sampling/CharacRrirrtion <br /> 0 Public Water Sgt., <br /> Ifdiff e'nmNV. We., ame —anew um <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alwaetk n/Modi6eascm 0 Test Hole 0 Other <br /> O Monimeing Well($)_N of wells ❑Soil Borings) rersrwos XGeohochnitel tSLO—oo`wd <br /> 0 Well Dcstmctian 0Out-04Serricc Well ❑Out-0ESeNicc Well Renewal <br /> 0 New Pump 0 Pump Rc la-c.t 0 Pump RclWr <br /> ❑Cross-Caracedon Repair <br /> WELLCONSTRUCrION vvv <br /> Drilling Method 13 Mud Rotary ❑Air Rotary )(Aur 13 Cable Tool C1 Push Point 13 Other <br /> Proposed Well Depth�It Eacavation r`4'h._�rr indiamem ❑Open Bottom ❑Gmel Peck l Grew]Sia in diameter <br /> ❑Cooducmr Casing indiameter I Coodumr Casing Depth _ft N <br /> Well Casing Diarnekr_in Tbic1mmVGaugeJASTM Schad O Steel 0 Plastic 0 Stamicas SRel O Other <br /> Grout Seal Depth ft 0Nest Cement(941h Eng/5-10gnhearer) OSand CaneN rack sru/7 gal waver T <br /> 06 m mte(20%solids) ❑Manufacturer Spot%solids % Name HcleAsEk sr"1 t. ❑Specs on File 13Space Submitted IV <br /> Cram Plasemeat Method 0 Pumped O Free Fall In Other_ ❑Retardant f l.ma Co..) n <br /> PEDESTAL Inetalled BV ❑Driller Cl Pump Cccuacmr ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in OChristy Ba ❑ <br /> aSlave Pipe <br /> PUMP ❑Submmible OTurbine 0Oeher HP__ Pumpkt ft Standing Water Level R (` <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ht <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS i ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION W WS. R, <br /> ,u NII N IM UM 74 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED � ---l(6�/'J�+gAVA`- TITLE I!l' DAT[ b4(2Ie Dy <br /> TrT _ <br /> At <br /> 4 // DEPARTMENT USE ONLY <br /> Application Accepted By tree—d"-- Dale 1014.4ry Area �) E.pkyee IDq <br /> Grout Inspection By(. Date ❑ SPECIAL Well Permit <br /> Pump ln$pa' By Date ❑ WAIVER Received <br /> Desttuttion Ins Y dete�a�lr�l2 I/ Comtrueted Well Depth it <br /> COMMENTS <br /> PE SC Recalled hat Amount Permit/ <br /> Codes let. By ash Herniated ata Servlce11 ues14 Invalad WelilUN <br /> af37 So /v'1o.u0 <br />