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R * :. <br /> , _ <br /> .a _. -� WELL/PUI�IP'I�ERMIT aSCiJ4��t�� _1 a <br /> $ANJOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE J""FL-STOCKTON CA 95202 .1209)468-3420 <br /> 1 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOa ADDRESS — z'Y LO Z I u �' CITY/ZIP <br /> ZOO/ y <br /> �f e <br /> CROSS STREET rv�V D ,y/to APN ®fO Q-S1eSD^.�? PARCEL SIZE L.�LAND USE APPLIUIIONtl y <br /> O"ER NAME ��„' ii- C,/0� / PHONE �1a6- b Y't 9 fR9 t <br /> 0"ERADDRES, �(/a ��-(),lZ`lr f� CMY/$TATUZIP — r <br /> CONTRACTOR /♦ -rf/�-A 6Aar- }lot PHONE^ 2_ <br /> CONTRACORAODRFSS4 ui aw/' /�17 �/J CITY/SrATE/ZIF <br /> SUBCONTRACTOR aa` e CSI V"77 1 PHONE -2yS- 2->a7 <br /> { SUBCONfRACTO0.ABB0.E59 CITY/STTATEMIP <br /> LICENSE C-57 E3 C-61 C!D-09 ❑Other NFMBER /3o'S EXFIMTIDN DATE -O — <br /> GEOGRAPHICALINFORMATION: Coordinates % Y Township_ Range_ SMlion <br /> INRADEU Use enesticiPrivate O Irrigelion/Agricultural ❑Industrial 13 Wear Quality Monitoring ❑Sail Sampliag/Chaactcrialion <br /> O Public Watersystem <br /> IftiRamtrrvm Ovmn. am Ram oras -- c4aum Narrear Foore Huracr <br /> TYPE OF WORK New Well ❑Replacement Wall ❑Well AlteahontModificadon ❑Test Hale C3 Other <br /> ❑Monitoring Wells) Hof wells 13 Soil Bom.g(s) rorb"tlaa OGentahnial I.flanw, <br /> ❑Well Destruction ❑OutAf-Service Well 0cut-0f--Service Well Rrnewai <br /> ew Pump ❑Purop Repiseenual 0 Purop Repair O Cow-Connection Repair <br /> WELLg Mttk UCTION ` <br /> Drilling Melhad�Mud*RoW{�rvn O Air Rotary Cl Auger ❑Cable Tool 0 Push Point O.ONer }_ <br /> Proposed Well Depth T.-Cuy R Bscavnion indiemeter 13 Open Boom ><Grevel Pack/Gravel Si. in diameter <br /> ❑Conductor suing indiamear / ConduelorCaing Depthft1 Well Casing Di eme a�in Thickne,NGeug&ASTM S had a 13 Sral "9;latie O Smi ❑Other <br /> Grout Seal Depth /00 R O Nat Cement(94 th hg/5-/Oge1 Rorer) XSand Cemrnt ami mk/7 gel waMr <br /> O Bermile(A2�0%solids) O Manufacturere Spe %solids % Name OSpesion File 13 Spices d <br /> s Submitte 'r <br /> Grout Placement Methoy <br /> d yv.umpBdOFr-Fell 9O1101 <br /> ❑Reorient/Acalmvtor(nartle) N <br /> ' I PEDESTAL Installod By Drilla ❑Pump Contactor C'"her�-fir C) <br /> t ❑Concrete RdeMal DimenOcas: Width fl Length -ft Thick i'b n ❑Christy lb. ❑Stove.Pipe rmen <br /> I PUMP submersible ❑N,hine ❑Other HP Pump Set R Sanding Water Level H 1" <br /> 1 <br /> I 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. 1 ALSO CERTIFY.THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFO_RN_IA CONTRACTORS STATE_LICENSE__OXRD.AND;3HH�T:ITAM c(iUMPV1ANCE,WITH,ALL`;' <br /> WORKERS COMPENSATION LAWS -' ---- -- ._ - <br /> M,G)/NIMUM 24 HOUR ADVANCE NOTICEItEQUI�RELD.FOR INSPECTIONS <br /> SIGNED / rAi{^^ TmE V�/`^U /�• DATE <br /> a-14e-� 1 1111 1407 <br /> Pf <br /> ` 1 <br /> �V <br /> b .. _ __ _ - .-d <br /> DEPARTMENT U SSE�O�N�.L <br /> Honno theplM'B 4 d {HIE t7rIRAi B '��2inpldy`ePIDq <br /> Groin Inspection R Date SSS ❑ SPECIAL Well Permit <br /> ' PumP Inspection By Date ❑ WAIvER Received <br /> DmEmcdm Inspection Byn� Dale Construchal Well Depth R <br /> i COMMENTS L&1-01e Pa-CGmdz./� <br /> ' t PE SC Resudled Che" Arsount PermlU <br /> Cada Info B ash Rcmltkd Date SeMaB ua N lon lax Wall IDB <br /> 31.6 2�s.ufl (.bif-%af7nD()�2b/S <br /> I tfiro OSSoot J/O2I 720 <br /> ' Txoommn wxL�PUMr rEaurt <br /> srow 1 <br />