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WELL / PUMP PERMIT SAN JOAQtJIN COUNTY ,, NMENTAL HEAI.TH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)469-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEC lI EXPIRES I YEAR FROM DArx ISSUED Joe AD!IRE36 6179 0- SJ(fmwf Rd CITVrLip i CROSS STTCE1,r '` y, APN O 0 cy PARCEL SITE LAND USE APPLICATION# _ OWNER NAM! y/V DOf a �Z PNONC �r `S GG' OWMLR ADII d r.,e, CM/STATII CtxiTRACTOK 'A Kozns / , PHONE Y' 7 CONTRACTOR ADDRESS da •...+r-i _ /-772 CIIV/STATirILIP Ju Krq- SUPCON17RACTOR PHONE SUeCOKPRACTOR ADDRESS_ CITY/STATEILIP ^� Llc[rtSl -57 ❑C-6! ❑D-09 ❑Other NUMBER EIPIRATION DATE 49 GE+OGRAPMCAL INFORMATWN: Coordieetes X Y TownM4 Range Seethe ?itDomesticINvate O Irrigetion/Agricultural ❑Industrial ❑Water Quality Monitoring CO3 Soil Sampling&-haractenution 13 Public Water S�: Ifdiffarcetfrom ow Syobtm Nome Contact Warmrr Mum Numbew TYM OF WORK,}lll:�cw Well O Reply-.e t Well ❑Well AlterarionrModiflation D Other ❑Monitoring Wells) q of wells ❑Soil Boring(s) 0 of barww 0 Geotechnical N of boriap OOut-Of--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair -AtNew Pump ❑Purnp,Rep1wcment ❑Pump Repair WILL CONSTRUCTION DrlWng MedwdATMud Rotary O Air Rotary ❑Auger ❑Cable Tool ❑Push Point� E3 Other Proposed Well Depth alp—ft Excavation in diameter ❑Open Botlom .'tl Gravel Pack/Gravel Sine in diameter ❑Conductor Casing in diank-ter / Conductor Casing Depth ft Well Caaleg Diameter �in Tbickaess/GsugrJASTM Schcd ❑Steel *63tic 0 Stainless Steel ❑Other Grout Seal Depth�ft ❑Neat Cement(P4 lb bag 15-10 gal wafer) .$and Cement zaA� sack ruin/7 gal wale ❑Bentoni to(20%solids) ❑Manufww.Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Plaeewwrit Method MPumped ❑Free Fell ❑Other _ ❑Retarlant/Accelerator(name) ftpwfAL Installed By Iler 13 Pump Contractor Q Other t� ❑Conerets Pedestal Dlsrw"w:WIdt6 R Length fl Thick in ❑Christy Boa O Stove Pipe ubrncTsiblc ❑Turbine ❑Other HP_�� Pump Set ft Standing Water Level ft IhA 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION A7VD THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ff-i JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 2 1 `) $IGN6D !'Z/ �. _ iTrTLE�A-01 '� /�. DATiE �+ f. _O G A 4t*1 M R TA ENT WO Application Accepted B• to —7 Ara Emplovee IDk�,r��-� Grout Inspection Dtaly' �� ❑ SPECIAL Well Permit Pump Inspection s; Date ��_, J D WAIVER Received t� Ceastnected W,dl Depth R COMMENTS_ PE SC Receivedbee Annual Permit/ Coder lafo B Balt Rensitted Date rvltx Invokeg WeI11Ai ,S V wP0o�7a� U043-42406 WELL PUMP PERMIT V27rim