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- � 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COL74TV Ej fR0h M%7A1.JUALTH DLPART1ITNT 3M E WEDER AVE 3"YL-STOCKTON CA 95102 -(209)46&3320 <br /> NON-RMNDABI-E PFRRN T CALL(209)953-7697 FOR INSM-1 IONS EXPIRES 1 VEAR FROM DATE ISSUED v <br /> :I SADDRESY <br /> CROSSSrstrm ck_�1+ I�[d---AP\ O�PARCEL SV-E �LA-VD[.SE APPLdCATIONq <br /> i5 ! <br /> s► ,��`„? $� b Com,c IL: ,` _ �PH�O-N,E�_- <br /> Ow� � "�lERADDItE-SS l� `���hC-MISTATE!"L '_ <br /> 1� <br /> , RtoNE� <br /> 0 <br /> COM TUC79a ���p�t� - - . <br /> 31 <br /> C9,4TRACTORADIIRTSS ql b JAMW-e ^�— �iT/SfATC21P�vy 4 l- <br /> ISURCOKTRACTOH - __ _. PHUNC_. 1 <br /> SS a� a <br /> SI.eCOn7RACTOR ADDRESSlf•A�' <br /> ` 7.wmt C-57 QC-61 0D-C9 OOlher_ Y R A <br /> t GLoGRApHWALIrnFvR\UTIOVf C-ediaalm X! P_ -;T-.�.-'.'nehip Rats __ SteG°n _ f <br /> C1n�EnOED l:sE ❑OcIencsl,oPnvare ❑Irrgtsora' rict:ltnraT.�tf1 <br /> i,J <br /> i❑Public WaeS c <br /> :- •c ted <br /> TYPE Of WORK ❑New Well UReplacemrsst Well 11t4'e:l AheratisnVMt t_nelt/l l'1QfT�jTlks l'dl�-QLI1�C� 111 LJI�IJIuabrtei+ �� <br /> Ili,*6lhbs �1,v�irc ycd <br /> ❑Alrmitorirg Wcil(s) of wells ❑Sail Borinb(s)_. <br /> ❑well Desu=h.n ❑Ou'-0f Service Well ❑Otu-Of-Smite Well ReDead <br /> ❑dew r ❑Pumy Replacement ❑?ump Repair ❑Crass-CDrmttim RepRir <br /> w�EFt.ConsraurnoNCP T <br /> Drilling Method ❑Mud Rotary 17 Air Rrtay 11 <br /> Anger O Cable Tool O Mh Pant Otf:er <br /> Proposed Well Depth 5t X60 11 r=3Va:I0rl ul diameter 0 Open Botusn ❑Gmvei Pack%Gravel Sue in iRDlerOr <br /> D C.mduaar CA/�sing in cium-.� i Conductor Casing Dr+,th—, f. <br /> Well Caro[ Diaroete./S,L�-'T,n 7T,is r Gw 8,'-ISTM Schad _ ❑Steel 0 Pln tic 0 Stainless Steel 0 Other— <br /> Groul Seal D tn_ b-IOU 11 eat Crrnc-t(94 Ib 64/5-109al-Wer) 0 Sand Cema:t sacF mix 17 gal water <br /> eP� s- <br /> -;daom ni aide} facture:Spec°L edids_% Near ❑Specs m File ❑Specs Submit <br /> Grout Placement Method ytd 0 OLtiar_ - ❑Rwm&-o I Aocelerseo:(name)PE-DESTAL Ise tAtled I)v ❑Driller 0 P,-Imp C-tractor O C"J- _ <br /> A ❑Cnarrelt Pedestal Dimen9Dm: W:d-s d Length _ft Thick m 0 Chris Be, C]St-Pipe <br /> Pu7s� A�} u Sulrscmbe ❑].,b,- f1 Otho HP A,r.4 Se: ft Sdadi113 Water Level R <br /> I dEAF-BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TFM WORK 1411L BE DONF.N ACCORDANCE WITH SAT <br /> JO,\QL1N COuN,7v ORDLNANCFS,STATE LAWS.AND RULES AND REGUI.ATIO\S. 1 ALSO CERTLPY THAT MY RF.QSIFRED Ll(-L.%SF.LS i <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CO r MACTORS S1ATELICENSE BOARD AND 1"HAT I AM IN CO.1U LLANC'l:WITH ALL <br /> WORKERS CO.MYFNSATION LAWS. <br /> n 1�MINL14IUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR JNSPE(MONS j 1 <br /> =rmE• _)W�71.' �7Y<Q1-Yt�D�--n.is V �l I <br /> 2004 <br /> OUIN COUNTY <br /> ONMENTAL <br /> ..... — DEPARTMENT <br /> _ '~DF`. -ART TENT a SE ON 'Y <br /> J ',Area Employee IDM L r/y �/ <br /> AppLcelion Accepted By -/ �i�7 '/ <br /> i Groin Inspection By- _ Date- - ❑ SPE LN'ell Permit '! <br /> I PunV Inspect Tin Dy_ ----. L7a:e___._ 0 NYAmTRReceived - l! <br /> f Deswcuon Inspe nm By Date_ _ CaRetwhed Well Depth R <br /> jo <br /> COMB - TS _—.....- — <br /> eT <br /> 11 9C Aeeelred ltit; A.-at te Peruse! W ell IIW <br /> paService Rednnrt k <br /> Cada lab AmiHed <br /> l Z Q a � C)C1�3 ' <br /> 7rri LAIA CY, r�nD t�su <br /> 1 � � J <br /> ` arra: <br /> 1 <br />