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WELL/PUMP PERMIT <br /> SANYO.Camrl�OUNPY <br /> ENYfft0N"E?VP,,L HE#LTH DEPARTMENT 3048 WEEPER AVE 3�Fl.-STOCKTON CA 95302-(ZO9)161d420 <br /> NON-REFUNDABLE PERMIT-13 CALL 209 953.7697 POR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOSADDREIE 2 CITY/EIP AIl/1�'T <br /> I Jy ��-� <br /> CHOSE STREET f / APN w —��O PAR/C�EL ITE 1J <br /> TOWNER NAME `� PHONE�9eC 7- �O•y/�� NPP <br /> OWNEAADDRESS D <br /> ICYISEATVLIP pp�� ` <br /> CONTRACTOR / PRONE yy•z-- <br /> 17-71 <br /> CONTMCPOR ADDRESS CITY/STATEMP <br /> a StMONTRACTOR PHONE <br /> SORCONTRACTORRADORPSSS CT'/STATEMIP <br /> LM <br /> a� LICENSE 1 57 &C.61 13 D-09 ❑OtherNUMBER EXPIRATIONDATE �O <br /> GEOGRAPHICAL INFORM TION: COOtdinatea X Y Towmelp Raaga_ Seeder_ <br /> INTENDED USE meRiUPrinA Cl lrrigatimJAgricularal Uhdustrial O Water Quality Monitoring O Soil Sampling/Chenneriasiov <br /> ❑Public Water SP= <br /> T �Ifdifl l(mm em bin sine <br /> I TVPEOFWDRN SNOW Well ORrylMemenl Well [3 Wall AlYndan/Modificatio. ❑Tem Hole ❑Other <br /> ❑Monitoring Weli(s) ,mmeNet.eus OSoil Boring(S)_ nemherurbednar ❑Geeeahucal avmb.rmlawles / . <br /> 0 Well DeaHuctioa ❑Out-Of-Service Well [3 Out-0f-Service Wall R.M.1 X11 <br /> 7 eW purrp ❑Pump R m <br /> Iaceenl 11Pum Seats, O CrmrConneetion Repair <br /> Weer CONSIRULTON <br /> I Drilling MMbodd Rout, [3 Air Roury ❑Augea ❑Cable Tool ❑Ptuh Point O other <br /> Proposed Well Dar, _ft Excevafica indlameter ❑Open Bottom vet Pack l Olanl Sion —fi,diameter <br /> O Cotducar vg in diameter / Conducar Ca�sin�g Depth A <br /> Well Casing Diameter is Thick..WGauge/ASTM Sehd CG'11 ❑ Q "n O Steel Slainhass S)lul (3 Other <br /> 7 Grow Seal Deprh ` <br /> �_ft ONrw Cc.I(9416hug15-10ga/wRrer) OSsnd Cement ry$M x.*inti/7gel Water <br /> OBenania(20%solids) ❑Manuhett cower S %solids_% Name OSpasoHFile ❑Sppcs Submnr Sd <br /> Grout PlateI <br /> ement Method R<MPW 0`F as Fall ❑Other ❑Retardant/Amelaabr(ram.) <br /> PEDCTTAL Installed BY I_Funller ❑Pump Connector OOther <br /> jtk1f,`Etna Pedesal Dimensions: Width R Length 7 R Thickis0 Ckrisry Box 0 Stave Pipe <br /> Pump ,4ubmersibie ❑Turbine ❑Other HP Pump Set ZW11, Sending Water Level <br /> WELLDESTRUCTION ❑Open BMW. 0 Gravel Pack ❑Unused ❑Other <br /> sav, well Olammer Tmal Deprh R Depth to Water ft Cl Cadng m be ParaMbd ft._R b_ft <br /> I Sealing Material O Nat Cement f94 lb hu,15-10WTIw er) ❑Sud Cement aw:.k mrx/7 gel Water ❑Brnmnirs Pelkes <br /> ❑Bentonne(20%Solids) O Manufacturer Spec%solids_% Name OSmes,on File ❑Spas Submiped <br /> Placement Method ❑Pumped ❑Free Fall ❑Other .+ <br /> 13Com,4aua ith MtMliroom Cep ft helaw grade a r O Complete to Exiuing Surfine Pad <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Z M N M 2Y HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> r SIC / <br /> PIED TITLE I `e DATE <br /> 1l D J <br /> T J <br /> It <br /> cz <br /> 1115 <br /> AG IN.O N' <br /> Z _ <br /> 'D£PARTMENT�BS/�-07L'Y <br /> i���Applc lb Auep1T.v �,DDR 7lGJ NLZ�q.,mArea�' 2 £mb 1D11 .7 Q�� <br /> Groin Insp�Mdon By <br /> Data 62 ❑ SPECIAL Well Permit <br /> PumDlnspatien By• Dao 17 a ❑ WAIVER Received <br /> aas� ` , <br /> Datmttion Inspectice By Data Cooilructed sVdl Depth !1 <br /> COMMENTS <br /> _ 1 � <br /> PE SC Amount 1 Rowelled Dine Permit/ lovolmp Well lag <br /> I Cd. Info Remitted ash By Serviette uestp <br /> 143 <br /> EHD43-02-006 MASTER WATER WELL PERMIT <br /> 5A¢O02 0 <br /> 4 <br />