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WELL/PUMP PERMIT <br /> SAN JOACUIN CCUNM ENVIRONMENTAL HEALTH DEPARIMEN 1 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.&232(209)458.3420 <br /> NON-REFUNDABLE PERMIT UIWW.S OV.Of !g ethd _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDREss CRYZP tivilwil <br /> �. vT��a 77�]hr`�a 3 <br /> CROSS STREE'_ API A P V PARCEL SQE '� LAND USE APPJCATIO(h�e o <br /> OWNER NAME Latin z aw - !r�V 1 _ _ _ PHONE X9• / !3 w&[) ,rI <br /> Is. u .— <br /> OWNER ADDRESS CTTY/STATEfjJP <br /> CONTRACTOR T SONE x <br /> ` <br /> CPO _- lGOY _. CITYISTATVbP <br /> $UBGONIRACTCIR/I:pNSUITANTF / 01 PHONE <br /> SuaGONTRACTO ICONSULTANT ADDRESS I� Ct T TEfbp ` <br /> LICENSE -S7 C161 1).09 Other NUMBER� EXPIRATION DATE <br /> BILLING PARTY: OMMER CONTRACTOR SUBCONTRACTOWCONSULTANr <br /> DoMES11C WELL SAMPLING: General MlneratlCoflform Baden(4391) CibromocJtloropropane(4392) Arsenic(4393) <br /> INTENDED USE DDmeglclPnvate IrriOationlAgnculturat Industrial Water Quaky man"onng Sal Semp6ng/Charaaerbzel,on <br /> Nic Water System <br /> Il OUerert Wont o w-vt. vv"SyVerl Nemo CDMW Name IN P"Number <br /> TYPE OF WORK New Well Replacement VWI Well AherationfAAodifKation Other <br /> MWdanng Wed(S1 S of wells Soil BonnoW c of borings aeotechnical a u'xnnec <br /> Out-ORServlce wpk Out-Of-SerncD Well Renewal Cross-Conreckr,Repair <br /> New Pum Pump Reple -.t _Pump Repea_ Raise WeI CasmQ <br /> WELL CONSTRUCTION <br /> Drilling Method Mutt Rotary Air Rotary Auger Calvo Tool Push Point Other <br /> Pnipused Wvll Depd' n Erravanon m diamele,, Open Annan Greve#Pack'Gravel Size in diameter <br /> Conductor Casino in diameter I CdnductDr Casing Depth n <br /> Well Casing Djameter_in ThicknasVGauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Deptt. h. Neat Cemert;94 lb aagl5f0 qai aafwl Sand Cement sack mi■n gal water <br /> ©enionde(20%solids) Other_ <br /> Grout Placement Method Pumper Free Fad Other Relardart!Accelerator inamei <br /> RMSTAL Installed By Under Pump Cortlractor Oihcr___ _ _ <br /> �qts.. <br /> cretePedestal Dimensions:WWBI_ft Leopthn'hickn Christy Bon <br /> rMnide Turbint Other HP Pump Set R Standing Water Level tt <br /> 1 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 C PWA N t jLWS; <br /> i.NCE NC"'nCE REQUIRED FOR IYAPECTIONS-PLEASE CALL 249I 9 3- <br /> SIGNED. �/" � �1, T. /!/��✓✓�� IDA' /�! <br /> RE YAjFN7, <br /> N <br /> V <br /> �rti�lgaU1/V co <br /> 'I itNTN�O�p�� ENlI' <br /> ITT <br /> Nr <br /> OF <br /> l EPARTMENT US ONLY <br /> Applicatwn Accepted By Z Date I I a o�U Area I C' '-mployee IDI <br /> smut Inspection By Date SPECIAL Well Pemllt <br /> Pump Inspection By �^�:SY/I �T,i h l_ Uaie WAIVER Recoivod <br /> Sod Bomlg Inspection By Date Conslnicted Well Depth__ R <br /> COMMENTS <br /> PE SC Received Amount Permw <br /> cod" into itte <br /> Cash Remd °ems Service Re u t 1I u,volce s woR IDM <br /> 939 1 50 T7 <br /> ""110-eii nr i!)Q iY NLu.mUNi`ngRMn <br />