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Yid <br /> WELL/PUMP PERMIT <br /> SAN JOAQOIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"o11L-STOCXTON CA 95201 -(209)468.3GO <br /> NON-REFUNDABLE <br /> /�PERMIT CALL <br /> 209 953.7697 FOR INSPECTIONS EXPIRES <br /> 1I YEAR FROM <br /> 000.WoNgEg0.NAME _�?D r��LI/�� PROMDDANE ISSUED <br /> JOBApDRESS Crr,,Z.. 7S / <br /> S7R¢T AIN Ip7 t% <br /> PHONLL9Opr- 7 <br /> Q$F <br /> OWNERADDRTSS I3S N1 CTTYWATIMAP�"•."".r"+"'� F� <br /> CoMMITOR t LT L PHONE ' <br /> CON3IUCTOR ADDRESS l COY/SYATVZIP� ,jacz O <br /> $UBCgYTRACHIR PHONE <br /> SUBCONTMCTOR ADIMLS4_ CHYISTATEOP <br /> LImYBe Olt.57 OCfii OD-09 ❑Othu NUMBER EXM RATION DATE +" <br /> G¢OL'MPHICALINPORMATION: Cardlaatea X Y TowRshlp_ Raagc_ Sectim_ <br /> INrErceOUBe eddPnvea ❑IrtigetiodAgncultuOl ❑Idus0iel O Wats Qualiry Monitoring ❑Soil SamplinglCAameteriadal <br /> ❑Public WaterSysam <br /> Irwe..ahou0wro. eer nro. ..m --TN.Flac-N-nitur <br /> T OP WORX KN.F.Wcli O Replaxnim,Well O Wall Albeuou'Modifipsin, O Test Hole O Other <br /> O Mumwcv g Wdl(s)__ " El Soil Bonng(s)_ "mecotnonny O GcaRchnkl w.eN arhodml <br /> ❑WdI Destruction ❑OutOf-Service Well ❑Out-0f-Service Weil Reoewd <br /> O New Pump O Purnp Replacement O Pinup 11 O Criss Connadon R it <br /> WE"CON¢r' UCrI <br /> Ddifi g MathRd Asad Rotary O Air Rotary O Augcr O Cabk Tool ❑Push Point O Other <br /> Prepoad Wall DePIh 5P4z(Zft EAcawdon Z2 in diameter OOpan Bohan Amvel Pack,Gmrd Sim in diameter <br /> ❑Conductw Casing in diamcier I Coodwmr Casing Depth _R <br /> Wall Cad., Diamekr in ThicknedCaugelASTM Schd_ 1,4)9_ Cl Stool A411luab, Cl Stainless Steel 13Other <br /> Grout Snl Depth R ONeat Caneotl9elhhag/5-/Oym,Warar) OSam Cement ..ck mlc,7 gal Water <br /> KB-wnia(20%solids) ❑Manuficmar Spx%solids_% Nemo_ OSpecion File ❑Spas Submimed <br /> Grout Pbcemeat Mathd O Pumpd O Fta Fall O other Cl RamMant/Acxknmr(name) <br /> PEDESTAL lMmDtd By O Drillerrap Contractor C3Cd.,O Caeertte Pdeatol Dimenabua: Widt fl length_A Thick in ❑Chrbty Be. O SMve Pipe <br /> PUMP O&A"...ihk 0TurbIM ❑Other__ HP Pump Set a StudinRWearl.erel fl <br /> WELL DEgrRDETION 0Opens Boteam 13Greve)pack 13 Lamed ❑Other <br /> Well Diameter_in Total Depth ft Depth m War-r ft ❑Caving to be Perfontd tram_R ac_fl <br /> Setting Material 0Near Cemenl(9s lh hug 13.10,rl wars,) 13Smd Ccntent sort ma/7 gal wamr O Bentoldte Idles <br /> O Beemnite(20-%solids) OManutauwmr Spoo%solids % Name ❑Specson Fib OSpeea Submiltd <br /> Planuaeal Method O Pumpd O Free Pall O Other <br /> 0&mplete With Mushleom Cap It below grad, Cl Cornplete to Eaimng Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUM ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 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 /> M'/ <br /> INI�VI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> &cnel !/ / t- LIJ1CA.i"A.� TffunMlf�1'e DATE 7-10—OK <br /> 0 G <br /> 0 _ MID CM4 1.w <br /> l / <br /> 15z- <br /> I <br /> AN JO OU N U TY <br /> ury PAX DEPARTMENTUSE ONLY .1 �Q�/f <br /> Z�ppi�iat Id'Y Da¢ �n�-(O S A. �� Employs.IDN_is2 <br /> Grout Inspcetiw By Date ��/��el ❑ SPECIAL Well Permit <br /> Pumpinspadoney pas ❑ WAIVER Received <br /> Thawctim Inspecum By Date CaMlrveted Well Depth _B <br /> COMMENTS (.lC a2p- ro &A..S e)r SWQG . <br /> • PE SC Radvd Arraull PerWv <br /> Cada Info B Cash Remind Date Servke N aeM N lavolcN N West 1Dg <br /> t 13107 7.75 7 191031 <br /> eHDa3-02-W 1041 t/ Ayr/ - 2+9$aD MASTER WATER WELL PERMIT <br /> IV&2W2 K <br /> _ 4La Ge3(-rhw , <br />