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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER AVE 3`R-STOCKTON CA 95202 -(209)460-3420 NON-REFUNDABLE P-E7RMIT CALL(209)9S3-7697 OR INSPECTIONS EXPIRES I YEARFROM DATE ISSUED / JOB ADDRESS E tenon T,2Acy 9S3"7l _ y CROSS hl'REET APN 2-09-036-03 PARCEL Btu3�LAND USE APPLICwTNNI# 0 O"MNAMF. -7bmAt2JC (fommr.l4jam--4 PHONE Z09-936-/ ' ONMERADDREss 31_711 Rj-i .y SII r--A- Cm15TATVZIP Ta2A41.0 U{ `1537/z - J � PHONE h�AI F_AYYT= lL711-4311-GSIA CONTRACTORADDREM /YR 1`544-11 Lt16ST- /4kXC5uuM L CRY/STAZ -5-TCY9- A.11C4 `7-5?4 , SURCONTILCTOR -! IP6C 914M )CXpiree7"r A/ PHONE SUBCO"RAMORADDRESS DK dTY/STwiPlLIP j'7y)_Y'fpAl 952135' LICENSE C-57 OC-61 11 D-09 ❑Other NUMBER 22 EXNRATION D.T.—vO O GROGRAPHI ALINFORM.TION: Coordinate! A Y Township ' .5 Rangel 6 Section - INTEND6DUSE ❑Dnmestic/Private OIDigmion/Agricuimeal ❑Industrial oxer Quality Monitoring 0 Soil Sampling/Chasaturiatim ❑Publi.Water S-HIM Hmffner:rmm(T•' mr y.Rm .me can.Nannewineve NI Tm.OFWORK ¢[New Well ❑Replxement Well ❑Well Altemtion/Modihcation ❑Tent Hole 0Oher t/J AMoniening Weli(s)`4 JrfNANUS 05oil 0Ming(s) v°rS ia,, ❑Geotechnical aetiwnrip ❑Well Destruction OOUI-0FSmice Well ❑Out-O%Smite Well Renewal "'w Pmt ❑Pum ft laecment 0 Pmn Repair 0 CrucsLonnechon R it WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Ronny Auger ❑Cable Tool 0Push Point 11 Other Proposed Well Depth 12!f ZS/ A Excavation in diameter ❑Open BMW. ❑Gravel Pack/Gravel Sias in diameter ❑Conductor Coring indiameter / Conductor Casing Depth R Wass Casing Diameter 211 iA ThickncW().uVJASTMSe, had 40 ❑Steel Putti. 11 Stainless Steel MOther, Grout Seal DcpthO-5f4d-1)v1 X'Nem Cement(94 th bog 15/0,.1 water) OSand Cement eeor w 7gal waxer ' ❑Bentonite llO%solids) ❑Manu(ecmrer Spec%salla_% Name_ ❑Spans on File OSpas Submitxed Grant Pheemam Method Qnmped ret Fal ❑Other ❑Reesdant/Aecelentor(name) PEDESTAL Installed Ba XDailler O Pump Contractor C3 Other JKC.Oerele Pedestal Dimenslona: Width-15' it LatgthI Thck in ❑Christy Box MgtovPI PUMp ❑Submersible ❑Turbine OOther HA_ PumpSI Standing Water Level ft WELL DESTRUCTION ❑Open Bottom 0(imvel Pack t7 Untried ❑Other Weil Demeter in TMel Ueph ft OrMhta Wear ft ❑CasingWbe Perf.tWfran Nu-_R Sealing Material ❑Nam Cement(94 1b hag/3-10g.t wanr) ❑Sand Cement UNk els 17 gel water 0 Beammic Pellets ❑BenmNxe(20%aolids) ❑Manufacturer Spec%!With__% Name DSpeeson File OSpecs Submittal Piacemeet Method ❑Pummal O Fra Fall ❑Other_ Cl Conopku with Mushroom Cap R below grade 0 Cornpla,to Existing Surface 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. 1 ALSO CERTIFY THAT MY REQUIRED LS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE IT Nr WORKERS COMPENSATION LAWS. "G fViI 11N)MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS A G SIGNED laR:L�a%oDt.Fae�.�`ncu. TME. STAfi-(rF�GF(yaS� DArz -'O- 12004 INIY V R Ld\ N- \ �''4.i-,r -....�SDI sr•`^� t, ad '� .:1t j .s.••�-� Y` v •4�. .R a.\A \\ —�_�cam— _ -' •:® a L DEPARTMENT U N Application Accepted By Deu7// 4 Arne_ Employ"ID# Grow Inspection By Date_ b1 117ter/ ❑ SPECIAL Well Permit Pump Impaction By Lata ❑ WAIVER Received Deouctlom nemeim.By Dau Constructed Well Depth It corAM Ts S w MR/ AW V' IWsEa1L-01 I , Y A Le 9i 1' 4t i z ..ra oe. PE SC IR..ivad x114!0Amount rm elD Codes late B CC.h Remitted Dxe ServkeR trot# Invoke# We])IDN •i _ I I i