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/O0 WELL/ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)4hg-3020 NON-REFUNDABLE PERMIT CALL../20/9)953-/769177 FOR�I NESP/EC�TIONS EXPIRES I YEAR /�FROM /DATE ISSUED JOB ADDRESS 7C//� '.aN_FNiVf�F/K /�"LJ CRT/pZrip &Ag4MJ %-5z?z q; CROSSSTaEET klf DF LLCXJLI O APN cot-7""y XV- t(o PIARCELS�IJPE ONNER NAME / / f^'+� S~/_� /PHrONEE 33.3— ,y� !P! OnvNERADORESS !--;71I-V( Air /�/L� y� /��)��/ CITY/STATErLIP 1.C-,4yf1r Cl 4 ZL11 CONTRACTOR _ L�[!//a'�N�� l�/lT li/+�/,C/� /�l�' �' PHONE 93i 3zf�_ COMRACTORADDRES: Q CT/STATVLIP 15jp� rA SUBCONTRACTOR ryryASr=L-1SL/K1 PHONE SCBCONTRACTORADDRESS MpTA9Y44S- ZL� CTrv/STATEIZIP LICENSE -S] -6! ❑D-09 ❑Other NEMRERY&EY2- GEOCIRAPHICALINFORMATIOM Coardinetes % Y TBwmhlp Range_ Section_ INTENDEDUSE )o'eomn'idPrivne ❑IrripnioNAgticullwal ❑Indundal E3Welm Quality Monitoring ❑Soil Sampling/Chancraivuen D Public Wamr Syysatem IfOnDnmfrom0.ner, am 3,vAn am+ T.iMwI Hm—am on+ r TYPE OF WORK d"Wcll ❑Replacement Well ❑Well Alumion/Modifiatlon ❑Test Fine ❑Other O Mommring Wells) _ nmekm of.db O Sail BOring(s) numhrorbonnp C Geotechnlnl rmtbmefbednaa ❑Well Dsawction 130.t-Of-Service Well ❑Outof-Servme Well Renewal WELLCO R14.PO Pum R la-ement ❑Pu Repel ❑CrovLonnxtion Repair DTIurilingMd Rotary ❑Air Rosily D Auger O Cable Tool 13 Push Paim ❑Other Proposed Well Depth_ M R Excavatiw mdiartuter ❑Open Bon. ❑Gravel Pack I Gravel 51.—in diameter O Conducmr Cuing r in dian+ctcr / Coaduclor Casing Depth fi Well Cuing Dwnru: lo hicknesslGa TugdASTM Sched CL7tM ❑Steal Mastic ❑Stainless Steel 0Other 45 rout Seat Depth A ONty Ceinenl(94 th hag/5-70 Sol»vier) Vand Cement AI- mock mtr/7 gal water D Rcraonite(2096 solids) O Manufacturer Spec M solids I •/+ Name__ O Specs on File O Specs Submitted GroutlNu,nlml Melhod m ❑FTee Fall ❑Other OReulHant/Accelemmr(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor J) lther G1JKT/-Il}}Fj/L ❑Con"em Pedestal Dlmenaersin Width B lsngN_R Thick in C2 Christy Bos ❑Stove Pipe Pump ubmusible 13 Turbine OOther HP_ Pump Sp It Su E1ing Watcr Lcvcl----5!5—: R 11 WELL DEsTRUCTION ❑Open BDtmm O Gravel Pack 0 Uncued ❑Other C+ Well Diamcmr in Total Depth R DepUt to Water R ❑Cuing to be Perfamted from_R m R Sealing Material 13 Neal Cement(94 lb bust/5-I0 got+yuler) OSend Cement sack mu 17 Sol wTtcr I]Beamalle pellcts TT- C Renmmm(2&/,solids) O ManuAcIumr Spec a solids_% Name O Specson File ❑SpecsSubmincd Ah Placement Mefhud ❑Pumped 0 Free Fall ❑Other Z O Complete with Mushroom Can R below grade 0 Complete in Existing Surface Pad el 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE$ STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS .i CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL n WORKERS COMPENSATION LAWS. h MINIM[}�p- O VANCE NOTICE REQUIRED FOR INSPECTI NSy�'�p EASE CALL(209)953-7697 1 ` SIfIr+eD 7r'/P�` // �jJf�-L— E 4 - '. DATA 2G(JO a l il g7 Ne cr i F _ s N E P r Uk 9 DEPARTMENT USE Ajsaoon Acc egcr�A 9y Dam 2- 2 T+ Ales 2I L- &nployte 100 T.no t on By Dam ❑ SPECIAL Well PIPRdt 3Sump ins 'ems r Wt��0%,Lig ❑ WAIVERRecelvetl Ikavuction Inspection By Date Consuuend WIN Depth �`-""' R COMMENTS ++:l0+ . + ee��e•( PE SCReceived Check#I Amount Date Permit/ InvekaM Well Rest Codes 5$c B u Remilled Service Request# +1-3 bE - '22S t.- o j C:O3 006IReIj So - 1 30