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�s1�+ltA� S Uv,% Il-IA 0",x� WELL/PUMP PERMIT SAN JOAQUtN COUNTY ENvutoNatENTAL HEALTH DErARTMENT 6Q0 EAST-MAIN STREET-STOCKTON CA 95202-(209)46&3420 NON-REFUNDABLE �,PCERNOT ��p) ��(/y/ 'ryy., EXPIRES 1 YEAR FiR{'Om DATE ISSUED JOB ADDRESS �( 6O C—VV f Y V_.B UCRAC� CITYrLip w •J 10- CROSS STREET 49-'ILd, t-9— APN '—P Or PARCEL SIZE OWNER NAME S'72,1 y1I C.I.I C �VB��dy.-t�l� PHONE /��f� w/Jy[��J� •• OWNER ADDRESS U'7Z I W% 6I'w� ! G� CITY/STATE/ZIP ! (- J /J Z O CONTRACTOR iE Uft"33&,L 9X^ f,z9I' �PHOONNE I CONTRACTORADDRESS y��!V_AZH CITY/STAT1/ZlP t*pLl 'APT SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/&P LICENSE ❑C-57 116 ❑D4)9 ❑Otha NUMBER E.xPIRATION DATE GEOGRAPmCALINFORMATION: Coordinates X Y Township Range Section INTENDED USE mestic/Private laigation/Agneukural ❑industrial ❑Water Quality Moadmang ❑Soil Sampling/Charataeruatioe ❑Public Watcr Syst If different sea:OM.: we Sysmm Name Corrocr Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration(Modification ❑Tcst Hole ❑Other ��®1 k4o nomberofwNle numberofborings oumbcrofbori.V 1T✓ RIJL+�_ ❑Monitoring Well(s) ```�//��t 13 Soil Boring(s) ❑Geotechnical swsr < ❑Well Destruction -0f-Service Well DOut-0f-Service Well Renewal W.� ❑New Pu R lacemenl ❑Pttm Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling-Method ❑Mud Rotary ❑Air Rotary ❑Auger D Cable Tool ❑Push Point D Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sia in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diarmter_in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other Groat Seal Depth ft ❑Ncat Cement f94 lb bag/S-l0 gal wmer) ❑Sand Cement sack mir/7 gal water ❑Bentonite(200/a solids) ❑Manufacturer Spec%solids % Name ❑Spas on File ❑Specs Submitted Groot Placement Method OPurnped ❑Frce Fall ❑Other D Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ft Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP D Submersible >=rbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCnON ❑Open Bo tom ❑Gravel Pack ❑Uncased Q Other WeiI Diameter_in Total Depth ft Depth to Water it ❑Casing to be Perforated from R to ft Y� Scaling Material ❑Neat Cement(94 lb bag/S-10gal water/ 13Sand Cemen[ sack mix i 7 gal water ❑Bentonite Pellets Pr1ACV r D Bentonite(20%solids) ❑Manufacturer Spec%solids a Name ❑Specs on File ❑Specs Submitted RECEI YD E Placement Method ❑Pumped ❑Free Fall ❑Other YY'' 13Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad � C L/ 1'1 „ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL BE DONE IN ACCORDANCE WITH SAV 0 01 JOAQUIN COUNTY ORDINAN S STATE L 'S,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS "IN�OgQV v WORKERS CO l - A CONTATE LICENSE BOARD AND THAT I Alf IN CO�H'LL4NCE WITH ALL ; RENCCU TRACT'O l:jyT IIIIY t / '+)'LCI il,. / TMOVT TITLE . 11� DArE REv !'ribou E® �T052016 EI1ll/IRtNrMENTAL y is PERMIT/SERI/ICES�rH DEPARTMENT USE N Y Application Accepted Date AreaEmployee ID#'1� J Grout Inspection ByDate ❑ Al We11 Permit Pump Inspection Hy____ Date ❑ WAIVERReceived Destruction Inspection By Date `\ Constructed'hell Ipepth n COMMENTS t.??. Cl '=�'V .\�Sx.� �uC!j\, �.'e Q'Fi•d.l��.ftly 0 5 f ZO 1 t`� ''A PE SC Received Amount Cd. 1 - Remitted Date , ned 11 Invoice# Well ID# i 8 111. z s o EHD 43-024M WEB Wel!Permit and DcYlatanorA c 9i 1!2007