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v WELL/PUMP PERMIT <br /> SAN JOAQUIJ COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3-FL-STOCKTON CA 95202-(209)468-3Q0 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JDBADDREEe x14193 S. Aresrdf� (id Crr�Yr/p MA��eca 95336 <br /> CROSS HlREEf (JYf�la3L'L1 Cryr APM,3-Q(�-�$O-�( PARCEL SIZE�Q(LLAND USfARLIGTGBy, B <br /> OWNER NAME {/2yLTf� '1 R rain oft I F�PHONE 59//�� ��/�5� <br /> OWr1ERADDRESS I11RI '4 Y1 R CITYBya, V P_ IL1CIY lH -1536b <br /> CONtRA R tr l PHONE S2,2.- 142.8 �'T <br /> CON omorORADDRESS ` f CITY/STATEIZIP 1M.Axr,+a CQ �y� J <br /> SUBCOMMLTOR PHONE <br /> SUBCONTRALTORADDRESS CITY/STATEIZIP <br /> LuCemst >&57 ❑Cfil DD-0 11 Other NUMBER EKMRATIDNDATf <br /> GEOORAPHIGLINFORMATIOH: CnnrdleMea .0 Y Township_ Ranpe Section <br /> INTENDEDUSE VfDomxmfPnvam ❑Irrigation/Agricultural ❑Industrial O Water Quality Monitoring ❑Soil Sempliag/Characlerimtion <br /> ❑Public Water System <br /> lf,iffnnnftma Ove: Wane SYIMM Niimx oxt =war M u <br /> TYPE OF WORK-ANew Well Cl Replacement Well D Well AltemtioNModiRation ❑Ten Hole 13 Other <br /> O Monitonne Wdl(a) #of wells ❑Soil Barings) aeramap OGatahnial aerhmax " <br /> Li Well Destruction ❑Out-Of-Se virs Well ❑0u1-0LSer is,Well Raaewal V <br /> O New Pump ❑Pump Replacement ❑Pump Repair 13 CnoscConeaction Repair <br /> WELLCONMVMON <br /> Drilling Methnd'�1113 Mud Rotary Air Romry 13 Auger ❑Cable Tool 13 Push point OOther <br /> � <br /> PropoeN Well Dry ft Excavation 12y/ n.diameter ❑Open BottumGravel Pack Gravel Sin m diameter <br /> ❑C ar Cosi indiamemr I Conductor Casing� /ft <br /> Well C..I, Diameter m rtkness/GaugrIASTM Schur l/o� I ❑Btal'CO Stainless Swel ❑Other <br /> Grout Seal o O / ft ❑Nat Cement f94 IA hog/5-10 yu/wnre,) OSend Cement sock are,/7 V1 water <br /> mm(20Y.=lido) ❑Manufacturer Spa%=lids % Name ❑Specs on File O Spas Submifted <br /> Groat Placement Method ->Qumped ❑Fra Fell C3 Other 17 Retardant/Accelerator(name) <br /> PEDES-FAL Installed By ❑Driller ,X Pump CmAnator 13 Other <br /> ❑Concrete Pedeual Dimensions. Width_ft Lagthft Thick in OChristy Bar 13 Steve Pipe <br /> PUMP ❑Submersible Cl Turbine OOthef HP Pump Set_11 Standing Warm l-evel B <br /> 1 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 MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �+] <br /> SIGNED Scv �� TrrO: D�Akler DATF��� <br /> () <br /> G PPoo <br /> D <br /> N C <br /> 6 <br /> i- <br /> ulaotIONTki- <br /> XF1 DE PAM INr <br /> DEI ART MENT U E NLY �— <br /> Application Aaepted � /- � DR. Ara Employee ID#,f:C!K '( 1 <br /> G. Inspersion Ry v Date �'� ❑ SPECIAL Well Permit <br /> Pump Inspection By Dam ❑ WAIVER Received <br /> Destruct..Inspection By Dam Conahvcted Well Depth D <br /> COMMENTS / <br /> PE SC Reedvel Chet Amount Data PerrWtl lewke# We010F <br /> Codes Info B Cnh ReminM Service hest# <br /> t�� - WPOO26 <br /> ENDe]N-0OM1 WMINILV PFAMn <br /> NAM <br />