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WELL f PUMP PERMIT <br /> SAN JOAQU w Cooh-rY ENvutpnatEN`TnL HEALI D DErARTME VT 400 E ksT Stn tvS rn.EE7-STOCKTON CA 9SM-(209)4W3420 <br /> NOSH-REFUNDABLE PER.WT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Lo <br /> JOS ADDRESS r��.y V v`!_S. "— �J� Cir"/Zw 1►✓ 5ll <br /> V`•' a <br /> q C <br /> CROSS STREET APV f 1 PARCEL SIZE gee <br /> OwNERNAME yPHONE /�•l� <br /> Ow'NER ADDRESS ClAr5 _ C1TYISTATFr11P—%q— 4 7 ((/���•Cyy�i �/�/' <br /> CONTRACTOR Awnaq (J /r PHONE <br /> CeNTRACTORADDRESS-TWE-5•HW—-Z&,__-_-. CITVISTATEITIP <br /> SIACONTRACTOA PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE 0 C-57 hjn6 ❑D-09 0 Other NUMBER EXP11EATJON DATE <br /> GEOGRAPHICAL INEORatATM: Coordbalia• X. Y Towmhlp Range Section <br /> or <br /> INTENDED USE '1Private Irtigatior✓Agricutural 0 industrial 0 water(Quality monitoring O Soil Samplin&rhmaeterizat7on <br /> ❑Public Water Syst _ <br /> If diVTesent fimOw ata Symm Vane Cosset:`3amc ar P7pm NLtnher <br /> a 1� �4Tv�rjK OT woRx 0 New Well El Replacement Well 0 Well AltcrattowNfodiEcation 0 Test Hole 0 Other <br /> ©Monitorin g Well(s3 nwnherorvreBs O Soil Boirn(s) n bcr of Ws iagi 0Gcotechmicai aiml",9Tb'"t"Bc <br /> w s.�. t J,� ❑Well Destruction �/.OF Service Welt ❑Out-ofScrvice Well RCDewal <br /> W`�"� 0 New Re lacemicat/ 0— r 0 Cross-Connection R it <br /> WELLCoxsrnurnoN <br /> Drilling Method 0 Mad Rotary E]Air Ro=y 0 Auger 0 Cable Tool 0 Push Point ❑Other <br /> Proposed Well Depth ft Excavation is diameter El Open Bottom 0 Gravel Pack I Gravel Size in diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing D'ia=lcr_in ThicknessfGaugwASTM Schell 0 Steel 0 Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth h 0 Neat Ccment t941b bag/3-1 aga1 r weer) 0 Sand Cernem sack mint 7 gal water <br /> 0 Bentonite(2(r/.solids) D Manufaclum Spec%solids % Nano Cl Specs on File 0 Specs Submitted <br /> Groat Placement Method 0 Pumped 0 Frre Fall 0 Other 13 Retardant I Aceeltrstor(nate) <br /> PEnESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: -Width—ft Length ft Thick in 0 Christy Bas 0 Stove Pipe <br /> PUMP Cl Submersible rbine E]Other HP Pump Set ft Standing WawrLevcl ft <br /> WELL DEsrRucrtoN 0Open Bottom ❑Gravel Pads 0Uocased 0Other <br /> Well Diameter_ ____in Total Depth ft Depth to Water ft 0 Casing to be Pcrforau_d from ft to ft <br /> Sealing Material 0 Teat Cement(94 db Mag/S-19 gal water) 0 Sand.Cemcn4 .sack mir i 7 gal water 0 Bentonite PcRM7- <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Cl Specs on File 0 SpecsSubmiRed •S 4� � h! <br /> Ptaremept:Method 0 Pumped ❑Free Fat[ 0 Other <br /> 0 Complete wills Mushroom Cap R below grade v ❑Complete to Existing Surface Pad I)EC <br /> (/!`} � <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13E DONE LV ACCORDANCE WITH SAN 200 <br /> 16 <br /> .II COUNTY ORDINAN S.STATEIIIS,AVD RULES AND R£f;ULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS '''v JOAQ U <br /> Cl7RRF`iT AND A COTTRACTO TATE LICENSE BOARD AND THAT I Alt IN COMPLIANCE WITH ALL __ -St'1R �COU <br /> WORKC, 1 I 'i- JF <br /> " <br /> 5 2016 <br /> ENVIRn-NIIEN,,�1 HEALTH <br /> PrRM'T/SE;,C6 <br /> AD <br /> DEPART\LENT 015E N Y <br /> Applicadon Acccpled Date Area_ Emp{oyee JDk <br /> GromInspeclion By Date ❑ SPE AL Well Permit <br /> Ptmtp[rtspeclion By -- Date.__-_,_ ❑ WAIVERRecelved <br /> Desmuclion Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Recnfved Amount Date Permw Invoke N Well IDN <br /> ea Imf Remitted Service ueettl <br /> 8 S 2 0 <br /> EHD 43412-01%WEB Weil Permit raid De J.M[voa.doe <br /> 9.71?2007 <br />