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WhEllI YU1V1YYLrK1V111 JOAQVIN COUNT'ENVIRONMENTAL HEALTH DEPARTMENT 364E WEBER AVE 3"FL-STOCKTON CA 95202- (209)468-3420 #N-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED J A/ /L/ { LR O _ `ADDRESS .� '/1 +_IC Iti '�`(�V-r::f /Crry/ZIP i t°rS'i^�1T -"»y ]SS STREET ..+, S AIN Iib-U' �n t5.yr t 'e 11 �((�� PARCEL SIZE `4ER NAME ,yAAk Lfv —eLJ, / 1 •'-e J PRONE IvINER ADDRESS fj 1 r� 1 x �L •P/L+� J1 I ^I CMISTATE/ZIP V„I LTRACTOR /�lJ C`•("`e..✓5 �r I'f” y 1 IZ•�•r C, PHONE r" I FACTOR ADDRESS .^'��-4 ciI A.I. I'.v'e' enfl CITWSTATFIZIP �(y is kG rj VBCONTRACTOR PRONE CONTRACTOR ADDRESS — OTVISTATEIZIP : L 71;EN5E PG$3 ❑CJI 0D-09 ID other NUMBER EXPIRATION DATE �h 'rEOORAPHICALINFORMATION: Coordinates % Y Township_ Range_ Section 'ENDED USE O Di m"ItelPrivete O IrrigUlotl/Agrlcillumal It led,ourial ❑Water Quality Monitoring O Soil Sim,hrig/Characumeatiou A. i ❑PIublicW.I. tem r4c,Innis roeants eine amai i (; 'YPE OF WORK ❑New Well ❑Replacement Well O Well Alleration/Modification ❑Test Hole O Other ^� ❑Monitoring Wells) numb".I-1 i O Soil eoring(s)_ mmnb—fr cga' Cl Geotechnical ...barofiedny ❑Well Destruction ❑Out-0f-Scrvicc Well 0On-06Servlce Well Rmcwel L ❑New Pump IVRurnpRo,finamacm ❑Pump Repair ❑Cmss-Connection Rusair YELL CONSTRUCTION i.11ling Method O Mud Rotary ❑Air Rotary O Auger O Cable Tool ❑Push Point ❑Other oposed Well Depth fi Excavation in diameter O Open Bonom O Gravel Pack/Gravel St. in diameter t ❑GmMYCm!Casing in diameter / Condunor Casing Depth R i Web Casing Diameter_in Thic1mSwVGaugdASTM Schell ❑Steel O Plastic O Stainless Steel O Other Grout Seal Depth It O Main Cement(94 lb Irug/5-10 Sol wmrr) O Sand Cement :nci mix 17 gel water O Bencuthe(20%While) O Manufacwrer Spec%solids_%. Name OSpacson File O Specs Submitted Low Placement Method ❑Pumped ❑Free Fall ❑Other OReurdam/Acectustor(name) CN 'EDEtTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ 1) Length_R Thick in O Chnuty, Box ❑Stove Pipe Mr IB� Submersible ❑Turbine ❑Other HP 7r Pomp Set fi Standing Wamr Level ,SLI It it DEsraOrnoN ❑OPm Bottom O Gravel Pack O Uncamd O Other Well Diameter_in Total Depth ft Depth to Water fl O Cuing to be Performed from_R to td[ Sub,Material O Hut Commit(94111 Aug/5-10 guhvmnr) OSnid Cement sock nrix/7gal u,or O Benwnlre Pellets O Sermonic(20".solids) ❑MBO fi,.,u G Spec%mlids_% Name O Specs ou Pik O Specs Submhud L•Iammeet Method ❑Pumped[ ❑Fra Fell O Other ❑Complete with Mushroom Cap fi below grade O Complete to Evening Surface Pad HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ^AQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS LtRRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL JRKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQU.RED FOR INSPECTIONS TITLE DATE Y'r�I'C• S 4 r - 1 n DEPARTMENT SEON Y r Appllcadon Accepted By QA1�1 p ' Date - 1: vJ Area zIL Employee IDN C) gY Groin Inspection By .- - '/ _Date El SPECIAL Well Permit �,p-7 .' ' Pump Inspection Byi�7!'/.'*')(c.•�� `«_ �s�'`� Date -'� ❑ WAIVER Received YXsuuedon Inspection By Date Constructed Well Depth It 10)MMENTS PE SC Amount esF:Y.I Received Date Permit/ Invokaft Well IDN Codes Info Remtted iash By Service Request# + L —Q 1,-0 '5 w oo zsa I ID 43-02-006 MASTER WATER WELL PERMI r L;P003