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WELL/PUMP PERMIT
<br /> f- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 24-w 4,/. e N a e 7Cr i,- 4v� CITY(ZIP 7r'r�' D
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<br /> CROSS STREET APN /443 3 yoo?—PARCEL SIZE22--LAND USE APPLICATION# pr m
<br /> OWNER NAME I L C PHONE 7//421
<br /> OWNER ADDRESS �$, �4� CGY'O'N u4� �� CITY/STATE/ZIP A.-f Ce /J P1'1 4
<br /> CONTRACTOR G;{Z Ag s-i e -olt y. Z'd e- PHONE O_
<br /> CONTRACTOR ADDRESS t� �ir'N�MG'rZ _.4;a?W CITY/STATEIZIP_�U ��'$70 C. 45 3
<br /> SUBCONTRACTOR � 7�e C G'1"t /��/%1 C PHONE 4(I//'Irew
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<br /> SUBCONTRACTOR ADDRESS r S C�CITY/STATE1E/ZZIIP � /-1
<br /> d0 � e/—.-W?`�71
<br /> LICENSE C- ❑C-51 D D-09 D O-., NUMBER `a��/ / EXPIRATION DATE
<br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_
<br /> INTENDED USE D D_m j./P C I/A./Ag ...I ❑ ...t,. D W,,..O.. y M._n S.,,
<br /> ❑P e .W.,.,Sy,t..
<br /> TYPE OF WORK D N.-W- ❑R_._, W.., C W...At...�.. /M., ❑0,,,
<br /> ❑Mt.,,,.,W.11(.')_# ,w. ,X", 8-_(.)�. n....., C G...., .. x ...
<br /> M O.t-O.-S..,,...W F-O.,-O,-S......W. R.,...... n C....-C.,,,,..,. R,P.,.
<br /> D N.,.R, ❑P. P R. C P. P R. ❑R.-WC.-.
<br /> WELL CONSTRUCTION -
<br /> Drilling Method ❑M,..R..,r, ❑A„R__ C A,,,.. ❑C.-T.., XP,,,,,P.- ❑ 0....
<br /> Proposed Well D.P E,.., .--t., COP..13-t..
<br /> ❑C.,,dP ,C.0.e „m..,.,., / C..,a.,.C. .s D.P,e
<br /> Well Casing D,.- . T,.�.. ,
<br /> / ,./ASTM S.,,.a LS, UP-- LhSt.�� .S,.. U Ot,
<br /> Grout Seal D.. �„ J..t C...(94,.._15-10g.,_.) ❑S. C... . ...l7
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<br /> B..__.(20%. ) 7 0,,,
<br /> Grout Placement Method J P,.,.P.e F...F.�, L 0,,,., L R.t.,a..t/A«.., .,(_.m.)
<br /> PEDESTAL Installed By D D C P.m P C..,,...t.. C 0,
<br /> n Concrete Pedestal F Dimensions:W L. yt «T„ . -�Christy Box n Stove Pipe
<br /> PUMP ❑S„ .0 T„ DO,,.,_ HP P„ P S. S,. . W. ,L.
<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. 1 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 /> MINI M 2 OUR AD NCE ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697
<br /> SIGNE TITLE/T� S'U h f DATE '
<br /> C��ED
<br /> 20,
<br /> I A.R
<br /> 11 H L LL
<br /> / DEPARTMENT USE ONLY
<br /> Ar.Pii.....,,A_.r, By A/ •.�+ T u-4t4o7536--,D., / 7 /3 A.. Emr,i y .ID# 7
<br /> G..,In.P.ct,. By D.- ❑ SPECIAL Well Permit
<br /> B. D,,. ❑ WAIVER Received
<br /> L,.P..,, By D.- Constructed Well Depth ft
<br /> COMMENTS
<br /> PEC
<br /> Received Check#/ Amount Date Permit/ Invoice# Well ID#
<br /> Codes Info BY Cash Remitted Service R uest#
<br /> y Ws 0 412s 3q-
<br /> ip
<br /> a /S
<br /> EHO 43 06 U
<br /> WELL/PUMP PERMIT
<br /> 4/30112
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