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WELL/PUMP PERMIT <br /> SAN JOAGYIN CouNry ENWRONEENTaL HEALTn DEPARTMENT 600 EAST MAIN STREET-STOCKrON CA 95202-(209)466.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 77,703 S /+'/a c4/r/iwr Q-:.z <br /> CmRm 7r+c/ 95777 <br /> CROSS STREET_ C,I "F d(J APN':E� PARCEL SIZE TL 17 Laso USE A"U"ywN a fon <br /> OWNER NaaE TfI�1!_�d 14TCJ +4-1._ r3'i 39-L9_ p <br /> e�x pXgr1E <br /> OWNER ADORESS CITYISTATL7P <br /> CONTRACTOR <br /> PRONE mOOnesYYX-l7YS <br /> .KA r <br /> COMACTOR Aa_ Gaol APA SF <br /> rT /le,d Cm/Srwrr/Zw 'T�.. / rA <br /> SUBCONIRAOTOR PKONEyrs--e7l.2 <br /> Suacoxrw`croa ADDRE96 ?TGS' /✓�yAna�. Ql; Cm/6TATEMP .�cb/ e4 ZYSht <br /> LICENSE ❑C-57 ❑C-61 ❑D-D9 O Other Numese tf36 L S7 EuuuTpn DAre / Tl <br /> GEOORMNICAL MFOwuigx: Coosdlnaba X 37-L, -,V33 Y--/�l. Y17g"'r Townahlp— Range_ Section_ <br /> 1N1 mu USE DmresdoPdvale ^ImgatiONAgricratural Il Industrial 7.WOW Quality Monitoring F Soil SamplingfCharaclenzetion <br /> Publie Water System <br /> nmltWem ewioww ,,,Fw ,,,, <br /> TYPE OF WORK C New Well 'J Replacement Wen ` Well AAeretlonfMadi6ca6an ❑Other <br /> D Monitoring Wallis)_#of wells\]Soil Bolirg(s)_6 eorwssen - Geolarhnicai edeonnps <br /> C OW-OI-Service Well ❑Out-Or-Semite Well Renewal r CmasConnectbn Repair <br /> ❑NOW Pump ❑Pump Replacement C Pump Repair r Reiss Well Casing <br /> WEUCOMMUcnoN <br /> Drilling Method n Mud Rotary L Air Rotary ld Auger CI Cable Tool a Push Print ❑ Othe <br /> Proposed Wall Depth -5 S Excavation I? In diameter r Open BOHW L Gravel PacWGraval Slza 1n diameW .J <br /> :11 Conductor Geeing_N diameter / Conductor Casing Depth g O <br /> Well Casing Diameter_in Thicimess/GaugelASTM Stlred D Steel ❑Plastic L Slalnleas Steel :l other <br /> Grout Seal Depth It -l' Cement(94 to beyb-10 ge/Ivefor) 0Sand Cement sacknw7gNwaW <br /> Benot <br /> lOnite(20%sos) NOthef <br /> Grout Placement Method ❑Pumped CFree Fall _Other ❑RebrdaMfAcceblatoT(neme) VJ <br /> P of lU& Inahlled By ❑Driller n Pump Contractor L Other <br /> I'.Concato Pedestal Dlmenelons:Width_S Length flThitlr in CChdaty Bos ❑Stow Piple <br /> PUMP C SubmBn;ible]Turbine C Other HP Pump Set S Standing Water Level fl raa <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN S• <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS -1- <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Cc=�11JIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ��"'k� TIRE f—r E5� I!gzf DAM <br /> T SEEMS <br /> EMEEMEME <br /> EEENEEEM1 ME I F, <br /> D <br /> ---------------------------- <br /> DEPARTMENT USE ONLY SG <br /> Application Accepted By 4 l !'y- Area EmptoyaelDIt <br /> Grout Inspection By Date SPECIAL Well PETRIN / <br /> Pump Inspection By Date Z WAIVER Received <br /> Scall Boring Inepedbn By Data ??IZ4'/L CoratrucNNl Well Depth R <br /> COMMENTS �j1/J�nL S Lc�7ED�tU/b ln�Zl,E/WMZ,`gr-7ta?&9" <br /> L!ll7N G/ITI.G Er /7Y�9.�!-A=lrll�itl G3!4ClZ�' l <br /> PE SC Received Checl N Anum rd Deb Permllf Invoice 0 Wall 109 <br /> coM Info By Cash RemHbd Sallee Request 9 <br /> 4377 -1Zi 8399- S 12 Saiplqqqo <br /> EIO13ae WEumuNPPERwn <br /> 80101 <br />