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IDS ADDRESS <br />Cams STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CoN TRACTOR <br />SAN JOAQUIN COUNTY Est Mass TM, <br />NON-REFUNDABLE PERMI <br />of 7 749 F, 00 400)09 <br />WELL / PUMP PERMIT <br />DEPARTMEAT 600E ASS MAIN STREET - STocKTON CA 95202 - 4611-3410 <br />523‘ <br />,.? 1 to A, odavq.riso„ 3c7E? -5/33 I <br />Q hide id -pc 76087 <br />- par. <br /> CtraiSTATEMP ir/ <br />A?, <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />o Test Hole ci Chher <br />oombv.4 bx&H, <br />0 Geoteelintal <br /> mato-it touieg, <br />0 Out-OF-Smice 9.rII Renewal <br />TE PE OF WORK Cl New Well CI Replacement Well 0 Well AlteradonfMedifictilon <br />0 Monitoring Well(s) <br />Cl Well Destnic0 <br />Cl New Pastas <br />rm.:abet (quails 0 Soil Borings) <br />Cl Ont-OF-Sarice Well <br />1.441:f Of Irk 'af <br />ff de; <br />I umniummniurkfirmsjimmulibilindisur , <br />lILULihY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TIM WORK WILL BE DONE IN ACCORDANCE WITH SAN ,VJAQUEN COUNTY ORMAN S. STATE LAWS. AND RULES AND RE=LATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACT, ,Iti'/I1 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD ASH THAT I AM LN COMPLIANCE WITH ALL WORKERS OD <br />.44600,141, A 1'.4 SIGs ED dta'7V DATE <br />47. <br />JUL <br />dc) <br />ri 1)1:;:41 t,n/7-47117.)/ <br />""cAt'r <br />08 <br />2021 <br />Invoke F WeB IDF <br />SPECIAL Well Permit <br />CI WAIVER Received <br />Canaan/4d WA Depth ft <br />PE <br />Codes <br />Sc <br />Info <br />050 <br />PennW Da Received --(1 Ammo <br />Remittal <br />+-7 <br />Date Grant inspeclioD By <br /> <br />Pomp Ingextion By <br /> <br />Destruction Inspection By <br />COMMENTS <br />Date_LT5t1 <br />Daze <br />50'41 I. vzo,Avyk <br />b)( <br />SUBCONTRACTOR PHONE <br />SUBCONTRAC TOR ADDRESS <br />LICENSE 2( <br />CIEFTAnZaTry______ <br />•0?1 0 C-37 C-'.-6.1 0 0-09 0 Other Nt MBES 8;3 7717 EXPIRATION Dila <br />GEOGRAPHICAL INEOWILSIM: Coonftnates Township _ Range Settles <br /> <br />MENDLD USE 0 Baeleilic;Pritale 'Iptigation. Agricultural 0 Indostrial <br /> <br />0 Public Wale+ System <br /> <br />If differara bot,txttm- t;i0., n Nam: COCCIVI :VVVI,orThras <br />0 WaterQuality Ma-Morino 0 Sal Sampling Chvecterktation <br />WELT. CONSIST:GEM (1/4.1 <br />.......,..--...................,... <br />Defiling Method Cl Mud Rotary Cl Air Raary Cl Auger Cl Cable Tool 0 Push Point Cl Other <br />Proposed Well Depth ft Excavation in diameter Cl Open Bottom 0 Gravel Pack , Gravel Size in diameter <br />Cl Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter in ThicirnessrGatgerASTM &hal 0 Steel 0 Plastic 0 Standup: Steel 0 Other <br />Grout Seal Depth ft CI Neat Cement NI M tag! i-I0 gal HOBO) 0 Sand Came sack war i 7 water gal <br />Li 3a-flash° CO% solids) 0 Mannheim+ Spec "i solids % Name 0 Spars on ETU CI Specs Submitted <br />Groan Platentent Method 0 Pu.,,d CI Fix Fail 0 Other 0 Rawdaut i Aceeienetor Marne) <br />PEDESTAL Installed By 0 Drifter 0 Pump Contractor Cl Other <br />0 Concrete Pedestal sions: Width it Length 'Fick " 0 Christy Box 0 Stave Pips <br />—IIP—.g <br />t <br />Puma bmersiblc ftubine 0 Other Pump Set ft Standiag Warr LeiA it <br />WeLtDr.srfttri., <br /> <br />s 0 Open torn 0 Costal Peek Cl Uneasiest 0 Other <br />Well DiESOKT in TOW Depth ft Dqnh to Water ft 0 Casing to be Perforaisi From ft to ft iticalleg Material CI Neat Comm Min Dag ., 5-10 gd Darer) CI Sang C=IZITI sect oak i 7 gal %HOE, 0 Bentenite Pacts <br />Cl Bentonite 1200S solids) 0 Manufacturer Sim% solids Name 0 Specs on File Cl Specs SUbminM <br />l'taeuurut method 0 Pumpw-d CI Free Fall 0 Other <br />0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surf ace Pad <br />DEPARTMENTUW ORLY <br />Applicaticel AzurptcdIty owe 7/2 j 71 Ama tJ eig Employee MI brA <br />(91/elred- 9/-77.an <br />OCt Penni/ A.Nd ftectrierive dor ERD 43-02405 WEB <br />9, 1 ,2,197