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WELL I PUMP PERMIT <br />SAN JOAQtU-A COuwry ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL. STOCXTON CA 95281 - (209) 4"-3{36 <br />.VV:v-NEFUNDABLE rERMIT Q� f''� CALL (209) 9S3-7697 rc1R INspa-Tio*,s EXPIRES t YEAR FROM DATE ISSUED <br />JOB ADDRESS tom[' i✓ 7 % �y CavrLI P t 7/ <br />CaDSS STREET 1 f/J1 e T R J 1ii0!`� _ L�1L APN 22 �� � 30-03 �PARCEL SIZE �y <br />OWNER NAME j�P"HCUCE <br />OWNER ADOUSS V 4.5✓ C.1STATE1L1P A!Qe/!i <br />CONTRACTOR PRONE <br />CririrtiACtoaADDaass _...... Y✓ 1/1 d Lir Nl Ci xrwTT� w� L.✓T (� _ <br />SubcwTWCTOR PiH#iB. <br />SVBCON IHACTOR ADUPASS CITYISTATEM P <br />LICENSE 12 C•57 0 C-61 00-09 D Other NUMaER a %/.'..) & EXPtRATA)N DAiz 2 40 <br />i.wrsi3ruiw n Y Iow"wo Range Section <br />INTENDED USE C lmiyatiWAVXUhura3 0 Indttaeia3 ii Water Quality Mositating C Soil SampltnglCh6ra00=i0n <br />0 Public Water' Syyatom <br />tdil7 "t tram Ow, sNr04MW NAVA ar <br />TYPE OF WORst C New Well 0 Replacement Well 0 Well AlteratioWMod#$*ttos CI Test Hot D other <br />C Monitoring Weil(,) aanil r d gib 0 Soil Boring(,) -01-61— ❑ Geotzcha cal <br />0 Well Datruction 0 Out-orsmwe Well C Out -or -Service Well kawwal <br />rl Mean Pam beo"— , iwniera, , n o,..,.., a......:. n r..._,, n ---- •.:_ <br />WELL CONSTAt1CrION <br />Drilling Method C Mud Rotary 0 Air Rotary D Auger C Cable Tool 0 Push Point a Other <br />Proposed Wail Depth ft Excavation n diaaxw <br />0 Open Sown, Ci Gravel Pack 1 Gravel Sia in diameter <br />O Conductor Casu g in diameter / Conductor Casing Depth ft <br />f Wail Casio% Diameter _ in Thfckness/Gaugr/ASTM Sched <br />0 Steel 0 Plastic 0 Stainless Site C Other <br />Crout Seat Depth ii C Neat Cement (94 1h bag I J•10 gat watrrrj <br />0 Saud Cement - sack arix 17 gal water <br />C Bentonite (2rP/s solids) 0 ManuO coater Spat % solids VName <br />i i Spoes on rile 0 Specs Submitted <br />Groot Phreemtnt Metbad ❑Pumped 0 Free Fail C Other _ <br />0 Retardant I Aweieraurr (name) . <br />PELEsrAL Iasialk4 By 0 Dn;kr 0 Pomp Contractar <br />0 o7dw <br />C Concrete Pedestal Dimemloas: Width R Loa <br />ft Thick .........._ is Ci Christy Box 0 Stovs Pipe <br />pump 0—bmrasibit CI Turbine C Otho HP <br />Pump Set - ft Standing W. Level ft <br />WELL DESrauCrtoN 0 Opm Sodom 0 Gravel "Pads O Utueaed <br />D Other <br />Well Diameter _in Total Depth ft Depth to Wow <br />ft CI Caning to be Pitribraw horn ft to n <br />Seabug Material C New Cement (941b &t&, /5.10 gut ivarsr) C Sand Cement <br />suck Aux 17 gal water is Benumite Pellets <br />C Beutomw (1W. solids) C ManuPaowrer Spix % solids % <br />'Name C Spoes on File is Specs Submitted <br />PPactment Method 0 Plumped D Froe Pail 0 Other <br />_ <br />C Cimtplete with Mushroom Cap R below grade <br />C Complete to Exatins Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APTLICATiON 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 PORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS TION <br />MINC ANCE NOTICE REQUIRED FOR (INSPECTIONS— PLEASE CALL (209) 95J3,-769 <br />StsED„__ TtTiE.S_".�.- DATE ...1Ldl.t:...7''1`.�_ <br />Application A -opted By <br />Grout lnapection By <br />Pump Inspecuon By <br />Destsuotion inapectfanB <br />COMMENTS <br />yl <br />to <br />�i <br />MCh t -USC: t3NLY "I �. J <br />Data !-i% Area t Employee (DVI Jyrl7"J'�"f <br />Date ❑ SPECIAL Wtll PerMit <br />Dae 0 WAiveR Received <br />rcac: ttecavea Amount <br />es ParpulY <br />CodInfo BDate Crib RertSerdiot stN q IR. ce r W� W* <br />IL <br />0 54� <br />i <br />i <br />£HD A3-02iOb MAMA WATER WELL PIERNUT <br />1,01002 <br />