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WE IT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT r � 304 E WEBER AVE 311°Ft,-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL - ECTIONS EXPIRES I YEAR FROM DATE ISSUED A4`,i ' L JOB ADDRESS �-v�/ ^ CITY/ZIP � CROSS STREET ,/ (LiC11�h Ya+1, ( f APN jqR`,�_ 0 05� PARCEL 512E t� •��, OWNER NAME � ' ��f t�I 3 crpof fo r j 4L C PHONE OWNER ADDRESS �/ , 10,01(c CITY/STATEIZIP Cr CONTRACTOR PHONE CONTRACTOR ADDRESS C ITYISTATEIZI P SUBCONTRACTOR L� �(N �G-i�� (X�1�/� fPHON�E SUBCONTRACTOR ADDRESS y — CpITYISTATEIZIP LICENSE C-57 ❑C-6111D-09 ❑Other NUMBER ( 6 Z EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑lrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/CharacteriZatiort ❑Public Water Sy-'tem ffdifferent from Owner: Water ysrem Name Conlao Naaw w P*e Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other Q Monitoring Well(s) numberofwells Cl Soil Boring(s) number ofborings Geotechnical wmberafborings ❑Well Destruction ❑Out-Of-Seryice Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Purn2 Replacement Q Pump Repair ❑Cross-Connection Repair SII.CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too[ ❑Push Point Other t Proposed Well Depth 'L 5 0 ft Excavation � 1 t in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Wel! Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941b hug l5-10 gal water) ❑Sand Cement ,suck[nix 17 gal water ❑Bentonite(20%solids) ❑Manufacture[Spec%solids % Name ❑Specs on rile ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fal l ❑Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed Py ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Pump ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level tt '9AMi6DESTRUCPION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Peri'orated from ft to tt Sealing Material Neal Cement(94 lh bag 15-10 gal wafer)WC P Sand Cenient suck mix 17 gal water ❑Bentonite Pellets ❑Bentonite(2(rsolids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIVY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS CO ENSATION L f [ 24 HOUR ADVANCE NOTICE REI+EQQUIIRED R INSPECTIONS SIGNED � TITLE DATE S F�+rl`- 4 r � / A ! ^ "`°° r r QU ld - _ �+ '' PUL, iC 16� N EN -Rn T, j f�, DEPARTMENT USE ONLY Application Accepted By 1 6WVIti" Date — Area 2 19 Employee ID# . Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By r Date ❑ WAIVER Received p y �� `'' Date ;Constructed Well Depth ft Destruction!ns cction r' r/`�ipi COMMENTS_ `` ='flGsL/�'r_' ✓.' _ _ : 'moi/ y.,Mfs r, -'/ J a'�..�. PE -SC Amount Check#1 Received Permtj' Codes Info Remitted ash By Date tutee Re uest# Invoice# Well IG`# I1WL OD300 EHD 43-02-006 MASTER WATER WELL PERMIT 5/712002