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WELLIPUMP PERMIT <br /> soo EA,T MAIN STREET STOCKTON CA 95202 -5209)499-9120 <br /> SAN JpAOtaN COUNTY ENVNtONM ENTAL HEALTH DEPARTMENT EXPIRES 1 YEAR FROM GATE ISSUED <br /> CALL_209)95 -16K IPa -Lq-TIONS ,- ---- -----.... <br /> NON-REFUNDABLE PERMIT <br /> ___—_-- k <br /> 12 CnY121n <br /> ,foe ADDRESS .A��,�- R HI <br /> 'f � RCEL Sr2E�O6 LAN .0 APPLICATION s re <br /> CRMSTREET_.!'�'"(_"_5.= -•-s--•.'c.— —_.'APN ±�iGJ.�.__�._ ws )� <br /> P� �Y�- �G <br /> ORWP NAME _._— <br /> QAen R AppREea P.-C, <br /> CONTRACTOR . .._.. __......_..—__- <br /> s�y�//y�r <br /> CONTRACTOR AOOREBS OrrbNk <br /> - <br /> C __.- <br /> SUBCONTRACTOR[L— <br /> [}Iher ' ! NUMBEN �_ E tPIAA npN OA/E J <br /> L--- of <br /> Y Township_ Range__ Section— <br /> At <br /> ection <br /> G.00RAPteCALINFORMATION: COOrdtrlat/a .—"--�I <br /> INTEAwaD Use �OomestiCJPnvate i IrrtgetkrvAg <br /> ncultursl I^drlsurat Water huably 1Aon,tbrinp Soil SampiingrChsmctenaation <br /> n aReren hem Owner <br /> -------ef - j <br /> TYtK Of WtNtK C New WRC Reptecemenl Well <br /> Other Well NtarelioNMUdfiration •Pr AP."ps a or bortnee I <br /> f or wells Soil Bonng(s)_ GeoteehnKa <br /> f Monitonng WAS)�_ rrnss•Conneceon Repair <br /> 7 Out.Ot Se v F1' Out-01-Senor R WeN Renewal <br /> Raise vdeC Cas __ <br /> P Re ecemeni <br /> [ m. New Pu _ —.-------... I <br /> WELL CoNaTauc N <br /> Rotary , Air Rotary ..Augel Coble fool Push Pont C)tner <br /> �Ortlilnq Method Mud , <br /> n Exceveeon—_,—._m dlernetrr Open Bottom Gravel pactrr'�;revEt Sire .n diameter i <br /> jProposed'NMI DOP* it <br /> r Conductor Casing _ o diameter J Cnnducmr Casing Deotn <br /> n TNICknessrGaug Steel plastic Stainless Steel � Other <br /> eJASTM Schad i <br /> Wetf Casing Diameter� , , Sand Cernerrt sacrr mrx/7 gat water ! <br /> 1 Neat Cotnent(41 r,Aoag/5 If ga,wa er; —� <br /> 1 Grout Ssel DePth_.._t -R - <br /> 9entprnte(20%solids) t Other _ <br /> 1 Other Y Retardant-nrrelwata(namelg�,F 1 <br /> Groat Placement Method !Pumped • Free Fall -- <br /> iJ0AQUBY <br /> arAL Installed By. f Dr Ner Pum o Contractor — Other -- n ThrtM m �Chrfsty BOY I'.Stove Pipe <br /> i Concrete Pedestal Dimensions Width - R Length <br /> 7Y _ �7 <br /> O'Suornff0b;e�: 1�rOrno <br /> WITH <br /> C TtFY THAT I HAVE PREPARED THIS APPLICATION AND rl+aT iHF Wnai.50PK �CERTEfOOTHAT MYNE IN CREQUIREDELCENSEpS i <br /> OUNTY ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS <br /> CURRENT AND ACTIVE WITH THE. CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> WORXERSCOMPENSATI AWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICEr REQUIRED FOR INSPECTIONS <br /> _ TITLE--e^^�T' DATE <br /> $letEHD <br /> l <br /> t <br /> -4- —{_i- <br /> --- 1 1 1 —— 1-d <br /> �. <br /> YMENT <br /> r <br /> DEPARTMENT UrSE 0NL" <br /> �./..�./�� Alen Frnplcyee lea s7r"'F <br /> Accepted Dy r ._.--"- Date -"_ F SPECIAL Well Permit <br /> A�ikbdOrT oil <br /> Grout inspedton BY ,e j± ,�^ /7z6 WAIVER RQC8IY8d <br /> Date__ .-. <br /> PUMP 1— Fon Dy ft <br /> ' Onto <br /> Constroctetl Wan Depth <br /> Sea Boring In ton By <br /> COMMENTS <br /> ved hetk_:. Amount + Date I lnvotco a Well IDs <br /> Recei <br /> PE S Can <br /> Service Request s.� <br /> is s Into 9 i <br />