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WELI.It PUMP PERMIT , 1 SAN JOAQUIN COUNTY ENviaoNMrN"rAL HEALTH DLPAxTmENT 304 E W'FAER AVE 3"FE-STOCKTON CA 95201-(209)"111-3420 I NON-REFUNDABLE PERMIT CALL(109)9S3-7697")R INSPECTIOVN EXPIRES I YEAR FROM DATE ISSUED 1 it ClrY21r -r,.c _ /1 > C ROSS STREET r Itzzl APN aoq-i90 a3 PAR('CI SIZE%l Y1_-LAND USL_jAPPLICATIONR OWNER NAME Lk AJ �_ 1{TlA�1 _ PIKIhT 11IQo �,r DWNLR ADDRESS _J`Oy _r' �r ,( _ - _ —-- CITYISYATV7JP�/Q(S? } /5sl/u CorcrRA(TOR 1CO\TRAC70R ADDRISS CtTY/STATT/ZtP SUBCONTTIAMOR SUBCONTRACTOR ADDRL33_ CrTY/SrATEZ1P i 1-11 E ❑C-57 ❑Col ❑D-09 ❑Other ND+ttER _ EXPIAATION DAI'L CEOGRAIMCALINFORtlATION: ClloeARaee X _ 1' _ Toweship__ R■Rge__ Section_ i;;7r ED USE ❑DomesticlPrivst O Irrigation/Agticultunl O Induwi.i O Water Quably Monitoring O Soil SamphngKlnractenation ❑Public Water Syslem-- ---- _ Irdm hon 0— Jnr-.— _— ----1•— �PLa'e�ia�e Tl-PE OF WORK Cl New Well ❑Replacement W ell O Well Altaatinn/Modifiauon ❑Test Holc O ❑Monitoring We[Xs)__Mofwcils (3 . IBormg(1) •erb-.p ❑Geotechnical-- —0.1b—p I ❑Well Destruction Z1t-Or-Senice Well ❑Out Or-Savir-e Well Renewal O New Plump ❑Pump Repleccment ❑Pum R",, O Cross-Conaeenon R",, WELT.CONSTR1.1110N Dr11Btt Method ❑Nud Rotary ❑Atr Ruur) ❑Auger ❑Cable lool O Push Point ❑(hher Proposed Well L)cpih` _ _ _ R LRC1V2lILn— _ 1.dtameler ❑Open Doltam OGnvel Pock'Gravel Size- _ —mdurrttu ❑Conductor Cssng_ __in durleter : Conductor Caving DL uh _ R Weil Cesing Diameter_in ThickneavGaugr.4STM Sched O Steel O PIL ILC O Suinku Steel Cl Other -`- VJ ` Grout Said D cp1h tl O Neu Ccmcm,9J It,hag i 3-10 gut.urer) O S■ttd Canrnt sot k Ata i 7 gal Wafer I `I O Dalonit(20%solids) ❑1.Danuracturer Spec a sold& _ e Name -_-_— ❑Sf—on Fite 0 Sptzs Submitted (Grout Placesent Netted 13 Pumped C1 Free Fall ❑Other_ _ ❑Rrurdant l AocekntOr(name) PEDrsTAL IRS[■Ilad By O Driller ❑Pump Coelnctw O Defter O Coterata Pedestal Dltnesti■ss: Width _ N Length f: Thick in ❑Christy Sol ❑Stovt Pipe — PUMP O Submersible O Turbine ❑Other_ _-- HP__ Pump Set_ fl Sundial Waiter Level WELL.DSMUCTrON O Open Bato" IJ Caavel Pack 13 encased ❑Other Well Diameter_in Tool Depth_ ft Dhpte to Ws-.er __ _ft ❑Casing to be Paltoratod bpm A w__ fl \ y Seallat Material ❑Nut Cement(94 th bag/3-10&d++aver) Cl Sand C+.n. I__ sac*wiz 7 gal water ❑ftentomte Pelices `I I O Bentonite(2(?'/*solids) ❑Manu(aerurer Spa:su ds Name O Specs on File O Specs Submitted Placeeent Method ❑Pumped ❑Free Fall O Otkcr r� ❑Compine with Mushroom Cop_ _ , fl belnW grnk O Complete w Existing Surface Pad I HERESY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGUTAVON.S. I ALSO CERTIFY THAT ABY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW'S. D 1 'IN(UM 21 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS NED_ _ FnrLi (&t,L-,t}��_ DATE nm MJ IT - J N DEPARTMENT USE ON/LY S Application Aeceptad By_ 'C.--— _ Date /11Lv tJ_ Aro ;;z-I C, En-pteyce IDM 4 SG j J Grout(aspectim Flyj7_ _ E3SPECIAL Well PerMil Pump Inspectiat BY /r�2g�j � sv.`_ _ Uace_ O�r= - - ❑ WAIVER Received Destruction laspocdott By Uatc V.- Constructed Wen Depth ft COMMENTS ial4a...w ' o o Uo2c.• C om ,.-- �.vltiu PE a vived C w1i Antou Permit/Cells tars B- as Retained D.re Service heat R Invoice R Well IDN 6 I '/ yAe 1c, l/ 7 3 E11D t101�■ MASTER WATER WTI L PERMIT IL"3b'Md: