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yy WELL+ -JMP PERMIT ..(JUIN COUNTY EN\IRONAIENI"Al.HEALTII D{:PAR"I ME.NI" ill./ 304 E WEBER AVE 3"'FL-STOCKTON CA 95202IFr(269)469-3420 NON-REruN-DAIJLF.PERMIT CALL(209)953-7697 FoR INISPECI IONS EXPIRES 1 YEAR FROM DATE ISSUED LA /J JOB ADDRt:NN 1-7 3`J� Qd A-j CITY/ZIP��ilmi��, S ('RIINN til Hftl / rY� _J(r(-_��- AI'N 1".\NCf:I.SI%ELAND UXE APPLLIICAATIONII 0%%N't R NA\O'. `0/' �� li /11/f PHONE/&(L;d,5// ClIY/STATE/ZIP "1 Z� CONI RAC POR PIIONE CONTNA(TOR ADDRESS CIT\'/STATE/'ZIP SURCONTRA(TOR PHONE St'BCONTRA(TOR ADDRESS CITY/STATE/ZIP LIcF.NSE ❑C-57 OC-61 OD-09 ❑Oleer NOMN):R EXPIRATION DATE GF.(NIRAPIII(AI.INI+ORMATION: Coordinates X V Township Range Section INTENDED USE IA)mestic/Private R)rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water Systent If ddferrm ft-, ). .Ier,)uemNa— on..t —or u TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other EI Monitoring Well(s) N ul'wells ❑Sot l l Son ng(s)____ sof h-.p 0Geotechnical Nofbonnp - ❑Well lestmctiun ❑(ion-nl=Service Well ❑Out-Ol'Service Well Renewal ❑New Punt, ❑Punt t Replacement O Punt,Repair' O('foss-Connection Repair W1 U.CONS$Rt'l-PION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Ucpth __Il Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth Il Well Casing Diameter __ to -thickness/Gauge/ASI M Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sed Depth__..... It ❑Neat Cement(94/h hag/5-10 gal u.ufer) ❑Sand Cement suck mix/7 gal water O Dicntonue(-pD"v Solids) O Manufacturer Spec",a solids a Name ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped ❑1 rec Fall O Other _ ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other O Cuncrele Pedestal Dimensions: R idth Il Length_ft Thick in ❑Christy Box ❑Stove Pipe Ptnu' 1Subn,crsihlc ❑1 urbine ❑Other IIP Pump Set Il Standing Water Level fl 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINA%CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT ANCTIYP. \\Ifll TIIF.CALIFORNIA <"ONTRACI'ORS SPATE: LICENSE BOARD AND THAT 1 ANI IN COMPLIANCE Y L WORKERS C,I f FINN:\IION1.:\\\N. i IN IUM HOUR ADVANCE NOTICEPy-QUI :D FOR INSPECTIONS ) Y v TITLE_ DATE -11... . I r..-siq u I,n,..,,:n-.ro.`+f 3.1 I, - vrcY_ _I _f .,.o ny.- t• t / P"O,YCEL P _-P.lREEL J P.OFClI Q P.r.4lEL J Pq.PL'!C G y4 4:1 p 005 1 I I's «n JAUI UNTY 1iL!'r 3a ai 55 \ =.f! AL wrm�n •pro,ro.row,. .r....r,...r« kt 1\ ry rwyw EW Errrir. DE ARTMENT USE NLV / � Application Accepted Ily0,1c�( _y�'�/_ ____I)rla Arca 2' ( Employee IDq / 7 Grout Inspection Ily_ �� _ _ _ ._-- -- -/ Date__ ❑ SPECIAL Well Permit �X19 Pump Inspccliun B4Date / ,�" ❑ WAIVER Received IX•iruction Inspection fly vv// n Date Constructed Well Depth ft COMMENTS-P C-%( - 0S� G n Jt Pe(24L11 0—A if n j i e_ PESC Received heckq Amount Dale Permit/ Invo Codes Info N s t Remitted Service Re uest If 3.(A OS �-C-) o -7 ( 3h' �'SU S7� r 'c> > N'11 I Pi'�,r rl N\"11