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L WELL /PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 340 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED [F JOB ADDRESS { (� - DRR1 - - v,. CITYIZIP_�']-bGlc,^I-p r > CROSS STREET I APN Q PARCEL SIZE LAND USE APPLICATION# res OWNER NAME ,µ t.7O� YDU � -- PHONE OWNER ADDRESS (?—N CITY/STATE/ZIP [ Zd CONTRACTOR __ L%) ALL Ae e — K URL- `Ajs}D /rJ SDG PHONE CONTRACTOR ADDRESS-j! /p 0, f Aj,-VA A �t4,�rl-At E Sjt rr, + CITY/STATE/ZIP 5 O/6) SrZJ t� SUBCONTRACTOR _WALL)W E - kI)NI_ 4A)D /rF,*PC� PHONE Z09— Z34 -•"}42. SUBCONTRACTOR ADDRESS CITY/ST GIS ftE LICENSE jtC-57, ❑C-6l ❑D-09 ❑Other - NUMBER PIRA o DA GEOGRAPHICAL INFORMATION: Coordinates X 't Y A=P f71_/yhW(Qe i$ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Qu � g G 1i� �Clti7f � ❑Public Water S�stem Md by T Indifferent from caner: Wnter System Name th ! ion 'S e one Irl T�.ibll{I1 TYPE OF WORK ❑New Well ❑Replacement Welt ❑Well Alteration)Modification ❑Test Hole ❑ n 1, ❑MonitoringWells #ofwells ❑Soil Borin s Il ofborSngs Hurborings ( } g( ) Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary X Auger ❑Cable Toot ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter i Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth—-1 S tt X Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ' 8 Other MMI ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑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 ft WELL DESTRUCTION- ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to_ ft Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑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 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE j /I,1 � DATE I _ I2[] E EIGHT 'M_I L E_ IING 4 a 1500 I 800 100 100 700 - :.?L,!-IRITZ mCIR- r EtKHURN COUNTR t cwFa� ,� ' 9 �# �o i 151 RsraxE 3 t FFlpus GLn1 UI OAK R . - �P��° MARLETTE R0 W py. A TLEN I I S g g f YDR Ecru § ' 952 i i110R5 CIR 4 OPER u{LL �ISTC ix MINNNnER„vTy MryE �� -` 9J / o GRAi RE N OR kRR1lyF hR b3. L N K '�C•' � O^ PRA115[q Ava � a M IlL CFppf XSS �/ IT o enell ns Wyky s LE8 R0N OR "rF Rru_ DR it3 U SIEXERIRG Yt i NT 'i Application Accepted By L [�[. (�L.�-� .C, Date Area Employee ID# '�Grouf Inspec[ion By j°"" - Dkte- Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By 'F1 `""" } t, ''' Date" Constructed Well Depth ft COMMENTS PE SC Received he / Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# 'V'L 3�J _ EHD 43-02-006 MASTER WATER WELL PERMIT , 12122/2003 - -