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t213v /O" 7- <br /> WELL!PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304EWEBERAVE3aa FL•STOCKTONCA95M -(29)4684420 <br /> NON-REFUNDABLE <br /> //PEE�/R�rMIT ,�,{IPPA'CALL <br /> 209 95.3-7697 FOR INSPECTIONS EXPIRES I YEAR FROMDATEISSUED <br /> JOSADDRESS ({V© ^�f"-w KY CMIZI � <br /> • /� p <br /> CR066 SERC[T � �// APN /Q T QED� /P}A�RC/[)LSIu 3p�w�•a8 � <br /> OWNERNAME I l- /,FTI RnoNE %W--Z23 <br /> OWNERADDRM Y'/5J CITY/3TATOZAP <br /> f <br /> CONTRACTOR T H L e /�P�NONC �+I GGL��+/�vvr7 <br /> CONTRACTOR ADORegs J CITVISTATEI2AP <br /> SUBCONTrucro¢ PHONE <br /> SUW0NItuMGR AwRISS //Cl�WiSS��/TATU?AP <br /> I.rQxTe -57 0 C-61 0 009 E3 Other_ NUMBERED &Z 7 ERNRATHRI DATE <br /> GW W1CALINPD1aMATKDN: CaardtUtq X. Y TsWRIhIP_ RRRge_ Scathe S <br /> r <br /> INre¢DEDUsE omatidPdvaa O lmgation/Agriculturel 0lnduatrid O Warn Quality Monitoring O Soil Sampling/ChantYedgdon <br /> 0 Public Water syftem <br /> IfNRemt Ram Or'rA. uv mm amt T M u <br /> TY OPWquc cw Well ❑Replacement Well EI Wall AI¢nRonthlodiRgtion ❑Test Hole OOther <br /> ❑Maniwang Well(&) mm3- awlnr C3 Soil Borings) 01°'emorronas+ 0Gwwehnieal ¢m�bm o(bontts <br /> 0 Well Dm=fiw 0 Out-0f-Service Well OOut-Of--Service Well Ramwal <br /> 0 New Pump 0 Pmp A Imanenl O Pup Repair 0 Cmu-Conw.von Repair <br /> weLL CONSTRUI.TI <br /> DdNng Method ttud Rmary Q Air Ronny ❑Anger O Cable Tool O Pub Point 0 Other <br /> Propanol Wall Depth 509206 Exavalion1_in diameter DOpen Banom gavel Pack/Gnvd Sia in diummer <br /> OCund.Ra Casing iediameer / Conk w,CningDgth _ft <br /> wall c".g Diameter 6 in ThictneWGangdASTM Schad_-/4g,0, �. ❑Steel 14Qlast, O Sovalc sSaol OOther <br /> GNNrtSewl Depth R (3Neat Cagol,W1bhog/5-/OgolwMe,) ❑Sate Cement sad nc f 7 gal"Par <br /> Nortoni a(2(3%solid.) 0 Manufacturer Spec%solids_% Nems— 0 Specs on File O Spas Subrrinnd <br /> Gnu[PlMemaRt Method ORrmpW OFw Fell ❑Other OReU.NarrlA lentm(nemc) <br /> Peo " gggt&MB2 0Wtter top Camnctor 0VAha <br /> O Concrete Petleatd Dimembm: Widl A L.Sth ft Thick in O CRr4ty Roe O SOw PIpe <br /> PUMP 13Su6ocuible E3 Turbine ❑Other__ HP_ Puny Sn_A Svrding Water L. cl ft <br /> WELL DESTRDCTION 0 Open Bobom O Gravel Peek 0 Unused 0 Other <br /> Well Diametern Total Depth R Depth m Water ft O Casing b be Parli n ed fmm fl In_fl <br /> • Ending Malarial E3 Cement fy4/A 6vg/3-10galwwer) C1 Stand Cement suck m4/7 ed want OBeenram Pclbe <br /> 0 Beeneene(20%solids) 0 Manufemurm Spm%solids % Natant_ 0 Specs on File 0 Spas Sub weal <br /> Plagtmnt Mensal 0 Pumped 0 Fra Fall O Otho _ <br /> 0&PI..with Muduomn Up R WD.gande 0 Complete m Existing Sud.Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> rMINI�NUM u HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED f T_ ✓� Tmu: h r L/1100 DAT. 7—/ia—123 <br /> G <br /> 0 - G <br /> d _ 1, <br /> i - AFAI a: <br /> AN ia OU N U N <br /> ti <br /> Kul <br /> pyAy ��c�rn DEPARTMENT USEONLY �l <br /> ppligt�t�p _ted Y Date ��(D Q S Ary 1 1 Tmpbya IDN <br /> Growl Inepatim By Dara O SPECIAL Well Permit <br /> Pump Inge don By Date O WAIVER RetXJved <br /> Dgtrttcdon Inapectim By One Ceaalaeded wall Depth ft <br /> • COMMENTSJTc' Cr�raill d&,,e 6 d@e.✓/QeA' <br /> PE SC Reedyed Amount Due Parrett/ leq{reM Well IDA <br /> Codes Info B (dab Remleted rvke Bnta <br /> 1310 ZZS o D G51 <br /> EHD 434.-0wW 104-f3L/ !FQ - mclo MASTER WATER WELL PERMIT <br /> 12/611002 R A 5;wl_ 19ey.70 <br /> —47X4(ov,I+I'D , <br />