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WELL If PUMP PERNUT <br /> SAN W`^"`"COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT I CALL(2 9)957-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDREIS CT'/ZIP // �C/!'r/fZJY) �N 1✓ ��'+ <br /> /C)3 23u/3 )) �N� <br /> CROSS STREET � f APN PAR/CE/LISIEE/� <br /> OWNER NAME PHONE 4.44 ///IIFO FR <br /> OWNER ADDRESS S CrtVISTATE/ZIP 'T <br /> �30CONTRACTOR V20 bh <br /> I(�PyH�O`1N¢ /Vry�r'lhq <br /> fJ�,2�_ <br /> CONTRnLTOR ADDRESS CTry)STATVZIP_bdi li 1-)llJ)-- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS. ��� CITY/STAT?FJZIP <br /> —LbLICENSE C-57 r\l Csil 13 D-09 OOther NUMBER E"IRATIDNDATE I <br /> GEOGRAPHICILINPORMATIOM CoontimatM X y Township_ Range_ Section V, <br /> INTENDED USE Domestic/Priva4 ❑ImpdpdAgricultuml O Industrial O Water Quality Monitoring ❑Soil Sampling/Charaoieriadon <br /> 13 Public Water System <br /> lf,fiff—ftsurGaots, WGI. II.Nsec CCaR.U.Fr.—�r m u a <br /> TVP¢OFWORR New Well ❑Replacement Well O Well AherntioNMadifitation E3 Test Hole ❑Other n <br /> nun,Evalwelir number ef"mee r.ashmafbods, <br /> O Monitodn{W<II(s)__ C)Soil Boring(a)_ 13 Geomchnical <br /> O Well Destruction OOw-Of--Service Wen ❑Our-06Sesvice Well Reoewl <br /> New Pump O Pump Re locomen O Pump Repair ❑Cmses-Connection Repair <br /> WELL CONSTNUON <br /> Drilling MeehudCWMud Rotary O Air RotaryAuger/ 13 Cable 13Cable Teel ❑Push PoOther <br /> Proposed Well Depth�A Eaeevadan��in diameter [I Open Bottom )4Gm.el Pack/GoVel Siae in dirmeler <br /> ❑Conductor Casing indumeter I CondIHoo,CLeing Depih R <br /> Well Cuing Diameter.6—in ThicknadGauge/AS rM Schad fy�0 StmI vpla.Eic Cl Sri n Seel O Other <br /> Croat Seal Depth &U'l' R ONeat Cement r94 to beg/5-10 got were,) Sand Cemera NY , 3_w:ckmU 17 gal wttt <br /> O Bentonim(20%solids) OManufecmmr Spm%solids_% Name ❑Speceon File OSpoes Submitted <br /> Grout Placement MethodPumped OFree Fell OOther ORetardant/Acctlenmr(mune) <br /> PEDESTAL Installed By rills O Pump Contactor O Other <br /> O Concrete Pedestal Dlmenslou: Width R Length B Thiele in ❑Christy Bos ❑Stove Pipe <br /> pump Submersible ll Turbine ❑Other__ HP Pump Set ft Standing Water Level A <br /> WILL DESTRUCTION 13 Op.Bmrmn ravel Pack OUncesed OOther <br /> WeII Diamelo_m Total Depth ft Depth m Welo A ❑Casing m be Perforated from A to ti <br /> Sealing Material ❑Not Cement(94 lb hag/540hel water) 13 Send C=ent sack mu/7 gal wuer ❑Bentonite Pellets <br /> ❑Bentonim(20%solids) ❑Manufacturer Spee%solids__% Name OSpecson File ❑Specs Submitted <br /> Placement Method O Pumped ❑Fra Fall O Other <br /> ❑Complete with Mushroom Cap A below grade O Complete to Eliding Surface Pad <br /> 1 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM INCOMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M 4 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(2091955:3-76,97 <br /> SIGNED '� TITLE -eside DATE Na <br /> E <br /> f 13 <br /> A J RTT <br /> CES <br /> gTA,K <br /> IIEDNISIO <br /> I mat <br /> 7 Jct <br /> 1set, i <br /> 0ASL­ <br /> ef <br /> # =6= <br /> /I ,. DEPARTMENT USE N S�yy <br /> Application Accepted By '!* Date r. Arca ..7/ Emplayoe IDN <br /> Groat mection Date 13 SPECIAL Well Permit <br /> Pump lnspmtionapWm !o —/—d3 13 WAIVER Received <br /> Destruction InaPation By Dam Constructed Well Depth D <br /> COMMENfR <br /> PE SC Received ChaAmount P <br /> Code, Info Kv e Rammed Dale Service Request it I..1.# Weil IDN <br /> ( O �FV <br /> oS[� -d cu I <br />