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r) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D WEL /PUMP PERMIT FILE COPY ' <br /> NON-REFUNDABLE PERMITCA' 304 E WEBER AYE 3X0 FL-STOCKTON CA 95202-(209)466-3420 <br /> L{ 249 953-7fi97 FOR INSPECTIONS <br /> JOB ADDRESS <br /> 5 EXPIRES]YEAR FRO DATE ISSUED - <br /> V n �• r r" — rn <br /> CITY/Zip <br /> CROSS STREET <br /> � APN1�7^0-^T PARCEL$IZE ecf l� `.+l�y�jyd!'[CATIONH :J C <br /> - OWNER NAME !N✓ � �� `�� r <br /> 1f1f OWNERADDRE55 I.�(_��� ,I sl J w HONE <br /> 1/ _ CI7r1SraTFlZtp �l J r '. /1 <br /> 1f CONTRACTOR <br /> C PRONgar i 1—lf7lf3/— �j <br /> CONTRACTOR ADDRESS �' J, �C F <br /> 7FTY/STATF121P_1� ��� Jf"CS? <br /> $BRCDMTRACi'OR i c� <br /> SUBCONTRACTOR ADDRESS PHONE <br /> CITY/STATEIZIP <br /> LICENSE C-57 G C-67 0'D-09 G Othert. `f - -7 <br /> NUMBER Fr l ExPt RATION II <br /> GEOGR !ICAL INFORMATION, C00rdinates X �} <br /> YTownsttiP <br /> NTEND£D SE Ran e <br /> G Domestic/Private Q Irrigation/Agricuhurai g Section <br /> s G Industr; ❑Water vali M itoring ❑Sol m iin <br /> Public Water System T 494W 73P IfWNEED .4- <br /> ,p„ y7yp g/Characteriralin. <br /> / Ifditlerenr from Owner: axr ysoem ame '� <br /> on � ame r u <br /> TYPE OF WORK G New Well epiacement Well G Well AlteraliontModificationm <br />' 11 h4o610ring Weil(sS N oFwells G Soil Barings) M of G Other. <br /> Eodngs - <br /> OOut-Of-Service Well ❑ <br /> ❑New Pum Q Pump aof6anng <br /> ❑OuI-Of-Service Well Renewal G Cmss-Connection Repair (Z <br /> R lacemem ❑Pum Re air <br /> 7Pmpos-edWefI <br /> O/N <br /> l,blud Rotary ❑Air Rotary ❑Auger Q Cable Tool ❑Pysh Point ❑Other <br /> eplh2� n Excavation // in diameter GOpen Bottom/Conductor Casin ,Pack/OraveiSize_2w Grindiameter <br /> g in diameter ! Conductor Casing Depth fl am, in Th ickness/GaugdgSTM Schell <br /> Grout Seat D th "��-- G Steel Plastic 0 Stainless SEec! � a Other <br /> eP ---�t'�_.ft ❑Neat Cement(94 lb hog/S-1D bu7 wnrer) nd Cement _ <br /> �t�mni[e�� solids} GtrlanuFacturer Spec%solids Name r" -c suckmis/7gal water <br /> Crout Placemept Method Pumped C Free Fall G Other V§Pecs on File ❑Specs Suhmitted <br /> QRetardant/Accelerater{nam,I <br /> PEDESTAL nstaUed By G Driller Pump Contractor 12 Other _ f <br /> Concrete Pedestal Dlmensions:Width 5 H Length V fi Thick <br /> hri <br /> ' in ❑Csty Box Q Stove Pipe <br /> PUMP ❑Submersible G Turbine C70[her Rp <br /> Pump Set it Standing Water Level /O R <br /> I 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 RECULATIONS. I ALSO CERTIFY THAT MY 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•!-POUR ADVANCE NOTICE WilARIED FOR INSPECTiOFNS <br /> SIGNED <br /> TITLE DATE I <br /> 1P .-d i <br /> R J A 11 <br /> NVR M <br /> P R7 iE <br /> D E P A R TM E N T U E N L Y <br /> Applieation Accepte ,l /q <br /> Date (/ Area Empiuyee IDit <br /> Grout Inspection sy � L` � �$ <br /> Date�}-�j / [] SPECIAL Well Permit <br /> Pump Inspection By Date <br /> El WAIVER Received <br /> Constructed Well Depth J ft <br /> COMMENTS l^r-cr <br /> PE .. SC Received Amount <br /> Codes Info B Date Permit! <br /> Remilted Service Re oast# Invoice 4 Well ID# <br /> c- <br /> END al-aa006 <br /> IR9l1005 WELL Pl1Mn P�RMtY <br />