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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 309 E WEBER AvE 3-PL-STOCKTON CA 93202 - (209)968-3920 NON-REFUNDABLE PERMIT(� -�C\^A/LL(2209)953-76997/FOR INSPECTIONS EEX1IIIP/I�RyyES I�YEAR FROM DATE ISSUED JOBADIARESS l S[4 l�J L UVLr�'� 1�[/L CM/zIr f"1'//r/1.t1/ I/ CROMSt'ne" t'XflNt+ APN 065 2 lob 01�PARRCYIC��EL/S�IZZEE�3a (aa OwxeR NASIE PxDN[L419 � 1 OWNERA➢DPESC I CMISTATFJZIP r� CONTHArTOR PHONE O CONTRACTOR ADDRTSx (bx - CTEV/SrATFJZIP % O SOBCONTItA lft A PHONE SURCONTRACEORADDRISB 1 V/ TAT JZIP IV LICENSE OC-57 C-61 13D-09 C)Other NUMBER Ex%BATON DATE �J GEoeRAPHx-ALINFORMA ton: Caardlnates X Y Township. Raoge_ SectionU INTENDED USE Dorrteatle/Pdvate O I%igatioNAgriculmral O lodusuial O Water Quality Montmnng O Sal SamplinglChanemriatidn P Public Wamr Svskm a� Ifdieneer Wft Dwiv woosuwniiwm Cr.., vrcar TYPE OF WORK ❑New Well O Repkeement Well O Well AltemioNModi6eation ❑Test Hole ❑O:her ❑Mcnimring Well(s) _ nwnMrof welh El Sod Boring(s) ....cubo:., OGevechnieal numenufto i.' O Well Destruction ❑Out-Of--Service Well OOut-0ery f-OrWell Renewal O New Pum Pum laxment ❑pump Repair ❑Cross-Conneeton Repair .toe WELL CONBFRUCDOK SJi� DrtOtng Method O Mud Rotary O Air Rosary ❑Auger ❑Cable Tudt ❑Push Point ❑Other Proposed Well Depth ft Excavatum in diametet [3 Op"Bottom O Gavel Pack/Cmve1 Sta in dumerer ❑Conductor Casing ircim.cer / Catbutun Ching Depth ft Well Cuing Diameter_in Thicknerx/GaugdAS7M Sched O Steel O Plastic ❑Stainla Steel O Other "k Grout Seat Depth ft 17 Neal Cement,94 lb bag/5-10 gal water) O Surd Cement xack wtx/7 yl water t(�V O Benoreite(2D°h solids) ❑Manufacturer Sive%solids % Name ❑Specson File ❑SpecsSubmitted }l, Groot Placement Method OPumped ❑Free Fall 0Other_ ❑RN[.Nant I Accelerator(mme) o PEDESTAL Installed By O Driller ❑Pump Coutracrnr ❑Other Concrete Pedestal Dlmeasions: Width I.en 'Ihiek i OChri Box OSow PUMP Submersible OTmbine OOtlter R HP Pump Sas R Standing Water Level It WELLDemurnON E3 Open Boom. O Cstavel Peck O Uaeaed OOther Well Diameter in Total Depth ft Dept:to Wave ft ❑Casing b be Perforated fmm_A to fl Sealing Material O Neat Cement(941bbag/3-/0galnwrr) ❑Said Cement rack or 17 gal water O Bentonite Pellets O Benlonite(20%Solids) OManufacwrer Spa%solids_.% Name OSpaeon File OSpecs Submitted Placement Method ❑Pumped ❑Free Fell O Other O Complete with Musbroom GD ft below Fade O Complete m Hdstin Surfue Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS 1�11,1VIMU 24 R VANCE OTICE REQUIRED ROR IN TIONS—PLEASE CALL(209)953-7697 $M.NED(y..Ak7) TITLE DATE A 14 N k C H H H M DEPARTMENT USED Ly Applindoo Accepted By U Area Employee IDM Omut Impam y Dam_ 13 SPECIAL Well Perniit Pump lnspati Date -dam<. El WAIVERReceived II7 Destruction TO'lux tion By Dam Co..rueled Well Depth D COMMENTS PE SC Received Chadd'/ Amount Data PermW IavpleaR Wall Im Codes Info B Ronutl.d Servlet Requeste p ( l/*Jalk