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Tom.. , 1 5d�— j—�{� � S�� '°N AOS :6 9106 'Dap mull P 1 9Da� <br /> WELLJPUMP PERMIT p <br /> SAN JoAawm CouN1r ENVIRONMENTAL HEAL-M DEPARTMENT 18M EASY HAZELTDN AVENUE-STocKToN CA SS205-I709)4511.3620 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 9 YEARFRom DATE ISSUED <br /> or <br /> Jos ADZ;RESS 5&3,55-/ E Milton Rd c,,,OLinden CA 95236 p <br /> CRCSSSHEET N Fine RD API Defg/l0bq P�r�ry?STATsFb�pinden <br /> ARRQc LLSvr _--1 I)USE <br /> (AP(}Puc(A-}NapNi* I Q <br /> IOIVN-R NAME 1_ 7�. r 5 Iff.�' �1ryG22015- E" Milton RD CA 95236 <br /> cON- CroR 1'ur`riance Drillers. IIIc. PHONE 209--637-3554 <br /> ICaNTrtAcrORADORESS P. 0. 'T Dox 6¢ CrrY1STATEF7rP Linden, Ck q523 <br /> SuEcaNTRAcrOR PHONE <br /> S uscoN rRAcraa ADDRESS CrTWSTA-WIZI <br /> Lt-EvSE = G57 C-61 t -D-ug omer Numuu 3779'23 EliplRAnOVDAl� 7/31 /1 7 <br /> GEOcRAPHICAL?NFoaauratr: Ccord-enates X Y Township_Range Secti= <br /> Fi—Us> DornesdGPrivale -inigallanVAg icultural . Indust hal ?1Na:er Qu�iry A^anilof ng Soil SamplingfCY aade�iza e0 <br /> Public Water System <br /> I <br /> if 00—d frcmf e9I r lsacn amo a rrs cr mom Numoor <br /> Type OF WORK _Nev+'Vtaell _ Replacenenl[,Voll :,Wall AReral onlModiRration '_ Other <br /> ar Coma Geotechnical wolCsny� <br /> -Ntoni[aring'JYe1l(sj w Gi V:'Zl}S �� $Oil$anrag(S) <br /> I Out-Ol-Service Weil out-OlSeavhceLh' RI Cross-Connection Repair <br /> J New Pum =Puup Re lacemenl ai <br /> Puma Reear rriev Raise Well CaSJnp <br /> WELL C0147RUCMON ho 10 <br /> Drilling Method =Mud Rotary _Air Rolary Auger -Cable Tool _•Push Point - Olhar <br /> Proposed Well Depth tt Ex:.avatkm in diameter - Open BOttam = Gravel PacidGravel Sire in drameler <br /> Conductor Casirg in diamels I Conductor Casing Depth 11 i <br /> Weil Casing Diameter_in Nrkne-w0Gaune1AST'al Sched Steel =Plastic StainlenSteEI w O her <br /> Grout Seal Depth `l -Neat Cement(99 ib ba915.10 gal meter) Sand Cement sack n1ixl7 gal waled <br /> -Ber mr,ite(20%wlies) 5 Olher I <br /> GroutPlacernearMethod _ pumped r=reeFall =Other RetardanI?AcWlerat0t(name) <br /> PEDESTAL Installed By -Oalrer ,Pomp ContraCtcr- _ Other , <br /> -Concrete Pedestal--Dimenslans:WicAh N Leng th 7 THi�t in -Christy Bax Stove Pipe PA Y"r 'r <br /> purht+ A Sutmerstliei�Turbine .Other 18' Pump Se l llf7 1h Standing 4A'ftr Level rl [ rnAI N+ <br /> I 'AER55Y CERTIFY THAT I HAVE PREPARED THIS A0.PPLICATION ANO THAT THE WORK WILL HE DONE IN ACCORDANCE tNDli SAh1 J ��+�f1'fD <br /> „OAQU1N COUNTY DRCIMANCES, STATE LAV,1S, AND ROLES AND REGULATIONS- 1 ALSO CERTIFY THAT IAT P.cOUiREO LICENSE 15 <br /> ClJRREW AND ACTIVE V41TK THE CALIFORNIA COAITRAC70RS STATE LICENSE UDAR13 AND THAT 1 AM 1N COMPLIANCE WITH ALL <br /> WORKE '4PENSATIWJ LAVES- ,[ 2016 <br /> I INI M 24 R A VANCE NO"nCE REQUIRED FOR INSPEC BONS-PLEASE CAL!_(209)953-7697 ���CAQUW v <br /> $sGNFp �' TInE Corporate Secret 10-14-14.}--'i� ,r'.s�-�j&;DA6 'LAY <br /> i'%f <br /> 4 farylF� <br /> } I nn <br /> IIl�EV <br /> I 1 I I <br /> I q ' <br /> i I I ► ! 2016 <br /> � l i <br /> r <br /> TTAL <br /> l I I E41.7H <br /> EEMICES <br /> I i <br /> i 1 - I <br /> I <br /> Il h l <br /> III I <br /> I I <br /> I } <br /> ,P R-rmENT SE LY a <br /> Application Accepted Dale Area Em,nayee 11 <br /> C'Mut Inspection By Date PECI L Well Permit <br /> Pump laspecGoq By Dale 3 WAIVER Received <br /> Soil Baring Inspw9un By Dale Consuucted Well Depth it <br /> COMMENTS <br /> PE Sc Received ClleCM Amount Permit!Dam tnvoleers W911 IDA <br /> Godes Info B Cash Remitted ServiceRequestA <br /> S <br /> I I I 1 <br /> ./ 1Nc-LLfPVLP PERM:i <br /> .vlang <br /> Z-d VL9£L9960Z oul saolpC7 eouewnd dZ9:90 ZO ZZ Inf <br />