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t <br />r ` Iq WELL / PUMP PERMIT <br />t <br />SAX dOAQVIINCOuNrvE.'ftDdONXEATALHEALTODEPIRT!RENr 600E.41Nt4l.+SUM -STOCKTON CA 95202-0V%"&3425 <br />NON-REFUNDABLE PEP -MIT EXPJRES I REAR FROM DATE ISSUED <br />7DrADDRi 1��zS ��ucL? • Ci,):74Y. ° C� 9sz <br />�^- �> <br />76 <br />CRDS STREET G e.k%ty )/1 �/`�AP�f__ �� P.%RCELSI.Ed s"• s p <br />ONNER N.11iE ¢.�VrL— /V/ ice/ `-� �%-/'--- PxotE_ Q �'! `_! <br />OKPERADDRESi _�/ / /l/! / / D��GG// <br />co%m4CTOR <br />CD'tTA4CtOR ADDREss/� • O`er � f�%(/f/y � �O _ CIlt7$rATiiZiP_�/_ �� ��/ /V (/� l3 <br />SUBCONTRACTOR PHONE__ <br />SUDCON-TRACTOR ADDRESS CliLY/5Y.4,"i'l7.iP_ <br />I I-LmE 0 C•37 -61 Q D-09 Q O bcr� Yl ,iRER ✓ E cnxtrro. D.nx � / � _ <br />a,caw,x4rTt[curNFOR.u.tri0�: COtR?3LRates a --_ } Te%Aslllp_ Raage Section.— <br />i�'iEhOFA [%sE tic:Priraia O hrigrt mAgtictmtuiral Q Inds 9ml C W ct'Qcafih 1cTmittrcing Q Soil SarnpFivgClrarctctixatirm <br />(3 Public Wates S -stem <br />J If difi'tvxm 5rr: O a• -- �-- IiW�. Sl,mm �..n: ansa van::.,• tiu�A- +- <br />T%PE DF WO" G Nm Wcii ❑ Repiaccteeat Weil 0 Well Altaalna Atoditxzlon Q Test Hole Q Other -- <br />0 Nionhoring welws) <br />ther_❑MonhoringWelws) .<t; QSoil0GcoiccbB=l <br />fl wdl Destrwdm`J Q Out -O{ Sc: cie: wzv Q (Aaf-S- <br />-Onicz Well ftwwil <br />-- <br />0�Pip yphtmDRcptF-.wet Q?n.It,-P ' DCros,rOPau tiwawair <br />M owi <br />WE" it <br />DrWft McMW E3 ;tad Rohn 0 Air Ro4wy O Ax%w Q Cable Tool Q Push Point G Other <br />Proposed Web Depth ft Excavation it,, diametx Q Open Bonom 0 Gravel Pack, Gravel Site in diameter <br />Q Conduc!" caging in dianmr i Conduclor Casing Depth R <br />A's e6 CAsitts Diameter _ie Thicko s0Gangw.%STM Schcd ` ❑ Ste:i Q Platic O Stainjem Steel d Oiler <br />Groat SealDz <br />pth. (3 \cat Ccant tyd F bag! f. Juga) xmeri Q Sand CZW= _ wck air; 7 gal wa cr <br />fl Siem ah,121TS; solids} Q 3lanuta.-.tuer Spec of da _ _ 4a %ane Q Spas on Fiic i3 Spz" Subrr*twd <br />Greta Pktetneat Methad Q PmTo Q Frw Fall Q Other E3 Retardant • Acc-ktatur laam.) <br />PLDE .%L iAsalled By Q rhilf-r ❑Pump Coahwor E3 other _ <br />flConcrete Pedestal Dimensions: Wichh^ ft L.cuelhT Thick in ❑Ch"-Boi 0StovePipe -- <br />Pt:3)► Q Ssbmersiblc Q %[bine Q OA HP Pumz. &t 8 Standing Winer Le - .el <br />W t u D1smucrION Q Open Bolsom Q Grawl Pick a uwc d C2 Oster <br />Well D%anrzmt, in Tal Depth R DcPtb tv'A Z4r fi Q Casm9 to br Perrontat imm I to fs <br />$t4b" i ttterial Q %eat Caters !94 JJi bag i Jrtev! wutir/ Q Sad Coat ace sr� r ? gaI was G Bemoruu: Ptiic4a <br />Q !ii9iomw iwre solids) Q MatnrGtutr.r Sp a Iro sOTids _ " laur , O oR til. O Specs Sn4 Ra:ed <br />Pluermn Rafted 13 P=WW O Free Fall O Other <br />D COwpia : a ith MushrOOm Cap ft below 912& Q Comphxe to Existing stufacc Pad <br />1 HERESY CERTIFF THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK 1t7I.i, BE DONE LV ACCORDANCE WITH SAN <br />3OAQVIN COUV3Y ORDINANCES, STATE LOW'S. AND RULES AND 1 EGiTL•1TH)NS. I ALSO CERTIFY THAT '%IY REQLTRED LICENSE IS <br />CURRENT AND ACTTV£ VYITH THE C.ALVORNIA CONTRACTORS STATE LICENSE HOARD AND THAT I AJL IN COMPLIANCE 'ATM Ami, <br />WORKUS <br />SIGNS TITLE DATE r <br />Appiicil=A=cpwdw --f��/i - -- .. �. r , — A. q6K1 <br />Gr _ <br />oot Ittsptrtimm By _ 7 ! <br />Date T'�' ' O SPECM Well Peratit <br />Pompincp--m By if(G, -� <br />�3�� Q WalvERReceived <br />Ikstnxuon tnwection Ay Dana Constructed Well Depth _ ft <br />9i l l r2ml oticu rem and DcrIem iiv-due <br />w <br />,5SZSZ <br />RECEIVED <br />AUG 10 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />