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0 WELUPUMP PERMIT 0
<br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420
<br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED
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<br /> JOB ADDRESS �y� �• f� Lr I�7�Y• ".'e CITY/ZIP O
<br /> CROSS STREET -i 3 APN 14 3 yoO% PARCEL SIZE 2,ZLAND USE APPLICATION# m
<br /> OWNER NAME 4-4I • !^ C PHONE 7/5r /-2O �11?5r to
<br /> OWNER ADDRESS ,� SS' CGy'OMLYNB 5S CI1/STATE211 4-f ce 4 e/!"l
<br /> CONTRACTOR G',7 A41- a ECJ d. ZM PHONE 0 3
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<br /> CONTRACTOR ADDRESS �yz I/,-If&" ���Q CITY/STATE/ZIPIL Ods 2;
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<br /> SUBCONTRACTOR roe!y-e 6-d 1"il° e//Z l c PHONE 7 X/ VfI//• .7d
<br /> SUBCONTRACTOR ADDRESS AZ 3 Sr 4 r/ __e�� QCIT ISTATEJZIP1f�l/ d LiW'Yf7`wM
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<br /> LICENSE - C- ❑C-61 ❑ D-09 D O,n- NUMBER90,E ExPIRATKx9 DATE
<br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_
<br /> INTENDED USE ❑D._../P�._ C I/A, ... ❑I d ,• . 7 wa 1 Q.a,Mo,. ' S-.,S.- s/Cn. a •.,=.,,o
<br /> ❑P.....W.—Sy
<br /> 4.,............,Ow,,... W.-S,. -N.- C.„ - .m... „...N
<br /> TYPE OF WORK ❑N—W— OR_ ._m LWr CW. A...„ IAA El0n
<br /> ❑M.,. .—w� .(..) #-_-1 X-B....,,M Z•I
<br /> ❑O„•-O•-S.,_. We.. F 0,,,-O.-S..,,_W.,R.,.. ❑Coss-C—...,o R_,
<br /> ❑New P„ p ❑P_R_--- L P_R__ ❑R.—W-C.,_
<br /> WELL CONSTRUCTION
<br /> Drilling Method ❑M„„R-_ ❑X.R.,—, C A_, ❑C.—T- N"„ P,,.,,, ❑ 01.=,
<br /> Proposed Well D_ E, a„o d'-- C O,e„B.,- C G....I P.../G,..e S=
<br /> ❑Co„d,.�,o,Ca. 9 d,.m.... / Ca.,d„�.o,Cn, s D.p
<br /> Well Casing D....... Tn / Aga/ASTM Stene L S,- u R-,. L &....e„&. u 0
<br /> Grout Seal Dr er ' N .LCmr,.1(94,n g/5-109 ,w..e.) ❑S.—C.m.
<br /> ❑B..-_(20%._—)�) -10,.,
<br /> Grout Placement Method L P.-, d F...F. L 0•n., L R. 1d.. 1A_e ,
<br /> PEDESTAL Installed By ❑D...., 7 P.-,C
<br /> n Concrae Pedestal F Dimensions:W,d,.. L r v, Tn, . I Christy Box n Stove Pipe
<br /> PUMP 0 S. e❑T,.. 7 O,n HP P ,S., S,. 9 W• .Le
<br /> I HEREBY CERTIFY THAT I 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. 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 LAWS.
<br /> MININJUM 2 OUR AD NCE ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697
<br /> SIGN TITLE a A f DATE
<br /> V 0114 &q
<br /> rMENT
<br /> CENED
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<br /> /J DEPARTMENT USE ONLY
<br /> A_-,.., A_ B„ �,'S L4474,%�APrtD.. 7//7//3 A.. Em, y D# ��g4
<br /> IS—,I ,p „e By D. ❑ SPECIAL Well Permit
<br /> P.-, By D... ❑ WAIVER Received
<br /> Sod B.—,I ,P „o By D. Constructed Well Depth ft
<br /> COMMENTS
<br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID#
<br /> Date
<br /> Codes Info Cash Remitted Service R uest#
<br /> 3ao '/2S" /J•.a 7 3 1, 00 DC2591
<br /> a /S
<br /> EHD 43-06 WELL/PUMP PERMIT
<br /> 4130/12
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