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. /[7 L,. <br /> WELL I PUMP PERNJIT ` <br /> SAN JOAQUINCOU STV ENVIRONMENTAL HEALTH Or PA RT MEM VW E WF.BEA AVP.Y"FL.-STOCKTON CA 95282 -(209)468.34211 <br /> NON-REFUNDABLE PERMIT � CALL 1209 953-7697 R)RR�II%srEC- o-i EXPIRE 11`YEEAR PROM DATE ISSUED <br /> JOBApORk55 'Lf O (ry a[{J � F F Y CFCS'IZII �'►p i/—`•' _ <br /> CROSS S71:lET �SL•_ L Y I_ APN C 7)-3 Z _ PARCEL SIZE /r <br /> yyyy/�� LJ'{ <br /> OwrERtiAME �+�P''' f rd PHONE d181- � +� <br /> OWNER AflDRE5V rCLTY/STAT9r1AP <br /> CONTRACTOR 4 d-1 � � n.ONE �3 <br /> 3 <br /> ~ <br /> CONTRACTORADDR- (" CIly1STATFJZIP W L <br /> SUEICONTRALTOA PRONG <br /> SUBCONTRAS'TOk ADDRCSS,- CITVMATEILIP <br /> LICENSE Cl C-57 0 Cfi: Cl D-09 0 Other NUMBER E%PIRaTION DATE <br /> GEOGRAPIHCALINFORMATION: CorInhhWas X Y Township_ Range Settlor tr <br /> I-NTLNDED USE C3 DornesticjPri,atc 0 InigahunlAgncultuni O Industrial O Water Chiality Monitonng ❑SOLI SamplinglCha[acteliatlon [ <br /> 0 Public Water S a�trm V <br /> lyd,rrwan nem .w ye.a N— _ �ixii.c[ 1 + <br /> J <br /> TYPE OF WoRtc 0 New Well 0 Replaoerr[ent Well to Wctl AlrcrationlModiRealtor, 13 Tess HDie 0 tither <br /> Q Monitoring Wel Kar —berafns [2 Sa[i BaRRg(9) -my.efhormas number ofhorrn� <br /> ❑CitdlechnIca l <br /> 0 Well Deslruc[ion 0 Ou[-or-Service Well ❑put-Of-Service WclI Ret rwai <br /> O New Purnp, 0 Pum B W.'crrscTrt 13 P)jmp Repair 0 Cr=-Coaau,aon Repair <br /> WELL CONSTRUCTION <br /> Drilling Method p Mud Rotary ❑Air Rotary 0 Auger CJ Cable Too[ LJ Push Pain, Cl Lhher <br /> Prop-).ed Well Depth, ft E%1:1ivati0n to dtarneter 0 open Bolton 0 Gem.d Pack 1 Gnrel Siff in diameter O <br /> l 0 C.0W%1Or Casing in dian:txer I COTWucwr Caatng Dcpth _ _ ft <br /> Well Casing Diameter to ThmkneaslCAugelAS71LI Schod 0 Steel Q Plastic 4Swinle"Slee; 0 Other _ <br /> Groua Seal lxpth R 0 New Crnrcnt IW lb bag/j.201,wl wmer) 0 Send Cement sock trtlr 1 7 gal wa ler <br /> R Scnwntcc(239'.aolttis) 0 Manufacluner Spee:4 sa1i44_% Name 0 Specaon Pile 0 Speca Submitted <br /> Grout Placement Method. d Pumped 0 I me Fall Q Oilier_ 0 Revrdantl Acte€erattor(name) C1 <br /> PEni.1TAL- Irivalled$r 0[Inner 0 Pump Con!racmr 0 OJhrr [� <br /> Q Cone rete Pedealat Dlnsendens: Width A Length___R Thick in 0 Chrla y Box 0 Store Pipe <br /> PUMP ❑Submersible 0 Turbine 0 Other liP_ Pum¢Set_ R ending Kale[i-e�ei ft <br /> WELu DESTRucnoN 13 Bottom ❑Gere]Pack L1 Uncaaad 0 Other _ <br /> Will Diameter [n Tara1 Depth R Depth to Water A 0 Casing LO be PerfOraied frOM_ ft m R <br /> Sealing Marerlal 0 NW Cement 04 lb habl J-14 hal wulrcJ �i„5x rad Cen•enc__/_?L Jerk mix 17 gal water 0 8rn[omtc PrRru <br /> p 3c+mionirc(20%solids) 11 Manufacturer Spec%solids % Name 0 Specs oe File O Speen Submitted <br /> ?€,aerates Method ❑Plumped tee Fall C3 Other_ <br /> CI Cumpierr with Mushroom Cip R below grade 0 C:amplele In Existing Surface Pad <br /> i HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION Ah-D THAT THE WORK WILL BE DONE IN ACCO"ANCE WITH SAN <br /> JOAQUIN1 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 COMPENSATION LAWS. <br /> MIDI 1i7ki�4 HDif ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)933.-77697 <br /> SICNED �� - TITLE OwILtjL- DATIL <br /> Ire <br /> f <br /> 1 <br /> DEPARTMENT ONLY <br /> Appiipuut Accepted 3y rasa 7-� o Ace, Employer.IDX <br /> [haul Inspi en Br_ Mee Q SPECIAL Well Permit <br /> Pump[napa[lan By [hate 0 WAIVER Received <br /> Destruction Inspect $y Construe '011 Pith <br /> COh1MENIS _ l <br /> e <br /> PE SC Recti 012 ee Amount Prrmial <br /> Cadea Info B ash <br /> Remitted Dale Scrrirr Re ursf M -- ! a' well[DN <br /> I 05 <br /> x' ILa� <br /> EHD 43-DI-W6 MASTER WATER WELL 116RMIl <br /> 14.15/2002 <br />