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t 16500 WELL/PUMP PERMIT <br /> SAN JOA001 COUNT.*ENviRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 45205.6232-(208)468.3420 <br /> NON-REFUNDABLE PERMIT � CALI ;20J}953-7897 FOR INSPECTIONS EXPIRES 4 YEAR FROM DATE ISSUED <br /> r,..._ _........ <br /> �JosAODRE4S _ E. Mariposa <br /> CR ss 3TR 6T _. AP (l9"-----PARCEL SIZE 7 _7 C LAND Use Art"lcATr y <br /> �O%VN:".R MW4 <br /> Brent i, 61i..7 1.T r3 m PHONE ;- ' - <br /> OWNER AreREsS ..............7_.4tt9rrf$........__- �.. CMWSTATEIZI ; <br /> 3G;rr . <br /> CONTRACTOR doSc.a Pump PHONE `�1�,4�✓;1 9t332� _ <br /> CONTRACTOR A0DR5S6_546 S. California Street CITY;STATEIZIF Stockton, Cly ..9, 203 _ <br /> jSUEavbK'fgA.TaR - <br /> PHONE_„_.a....,,......._ <br /> ISUMONTRACTOR AODRESS GITYISTATEtZIP <br /> ,L,C!3 Se ❑Cw, I C-61 D P-09 C Other NumseR 724778 EXPIRATiONDATE 08/14 <br /> G�aoh W€ Ld 4RtaA dpi: COOrQ#n3tES X Y Township_ Range Section <br /> � '�0 ,t arnetllalPrivete 01rripatior Agric:iturat 0 Indus:dai 1.1'hater Ovahty Nionlicring 0 Soil SamplinglC»arectorizatlan <br /> t b Public Water 4yssiem _ <br /> r 61N§:rerttAY+m frivnax: WaTOr ,xm NAn ontam.Name or .ore"um er <br /> Tyea OPWOR. NowWe3 ❑Replacement Well 0 Well Alteration/Modification ❑Other _ <br /> t ianitering Weil(o) #of wells 7="Sol Boing(s) d ar oren�a ❑Gootechnical <br /> G 00t-01-sa vivo Well Out-91-Service Welt Renewal 3 Oross-Connection Repair <br /> ❑Now Pump 0 Puma WLi ':4trtemt a Re air ❑Reiso Welt Casno _a <br /> Drilling Method 0 Mud Rotafy D kir Rotary f�rage��❑Cable Tool G Push Point ❑ Other— <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom ❑Gravel PaowGravei Size_." =n d=.ameter <br /> orFdv x Oast g in d arnator i Conductor Casing D ih 1t <br /> Well Casing Oma r____ in Thiok*.e.� aui;*JASTM Schad ❑Steei C Plastic G Stainless Steel ❑Other <br /> Grout Seas pth It Meat Cement(94 lb begrE-',0 981 teeter) C$and Cement sack MIX11 pati water <br /> EentZmite soliusl U Other <br /> !Grout Placement Method ❑Fum.Ded.n Free Fah C Other _ C Retardant Acce.erator(name)_ _ <br /> �i <br /> P gInstallod By i.t 06116r ' Pump Contactor C Oths <br /> _ u Oorate Pedestal Dimensions Width_,,_,_ft Length ft Thick in 0 ChrisBox D Stove Pipe <br /> P stP�� mlbler i v hiaer 0Other_ Hp �amP Sat j _R 3taratr star Levi-rte .°t <br /> i HEREBY,CEI Y THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> J0AQUINkZZUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT PAY REQUIRED LICENSE IS j <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I ANI IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. i <br /> MIIUIII!A 24 HOUR ADVANCE NOTICE REQUIRED FOR 16 sn—c`rioimS <br /> 4Nri TIT.E C0 DAz _R-2_7-2j)14 <br /> _. _._._. .... r <br /> i <br /> r f <br /> d <br /> � �" gM'y�PAlP65R (yphb � ' Ep' <br /> F ? � <br /> Fhs+- <br /> �� <br /> ___....._...................._._.._ <br /> DEPARTMENT USE ONLY <br /> An'U,; ton A=.oted tip � t�t�d '.�fr"f Date� l! Area - -�, Employee 100 <br /> Groutinspection ey Date SPECIAL Well Permit <br /> .UmIntpsclSwt By Da a WAIVER Received <br /> Sed Borirrgrlion B Date Constructed Well Depth, Ii <br /> '.ns <br /> uOvlhEB#v#S <br /> PE 8£ Received fro Amount Date Permit! Invoice# Well ID# <br /> cod" into e _ cash <br /> Remitted Service Request <br /> It _ <br /> I,_ 9z <br /> a 9a weeuR�s -.. <br />