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WELL / PUMP PERMIT <br />SAX, JOAQUIN COUNTY ENvu ONmF^-rAL HE�A�T) DEPARTMENT 60 EAS[ AIN STREE['-STOCKTON CA"M-(209)4W342e <br />NON-REFUNDABLE PERMBT �`� `"•' /A� EXPIRES I YEAR FROM DATE ISSUED <br />Jon ADDRESS r�'� 2" &. / Z -141,>E -N1 9S1j <br />a <br />CROSS STREET _`/(`��/'N'_Q.��I'LRCELSIZYOWNERNAME <br />OWNER ADDRESS /,/CIITYiST//AATFMP <br />CONTRACTOR r�r� / ��" l"' —� PDoNr. <br />CONTRACTORADDRESS /D / D `� CIT%/SFATVZIP-----Iel —F-- 5V V LJ <br />SUBCONTRACTOR _ PHONE W <br />SUttCONTRACTOR ADDRESS CrTY/ST.4TEJZIr <br />LICENSE O C-57 C 61 O O F <br />D-09 Other NUMBER CJ EXPuLiTiON DATE f! <br />GEoGRAPD1cAL INFORaL1TION: Coordbntes X Y Township_ Range Section <br />INTENDED USE O Dm <br />oestic/Private lrrigation/Agricultural O Industrial O Water Quality Monitoring O Soil Sampfinv,�Cbaractcri�wion <br />�- O Public Wafr System <br />1f &&.at from orrveG I wooer SJxmm `lam: l'unlit Name rr Phorc Number <br />TtrEOF WORK O New Weff O Replacement Well O Well A)teralionlModilication O Test Hole Cl <br />0 Monitoring Wciks) —b—f`—U' 0 Soil Bormes) nmober of Wri O Ci otwlmical aamt.a of tx.;ngs <br />O well Destruction O Ow -Of -service well O Out -Of -Sen ice Well Renewal <br />WELL CONSTRU 1 N <br />IM ling Method O Mud Rotary O Air Rotary O Auger O Cable Tool I7 Push Point O Other__ <br />Proposed Well Depth R Excavation in diameter <br />O Open Bottom O Gravel Pack / Gravel Sill in diameter <br />O Conductor Casing in diameter ! Conductor Casing Depth A <br />Well Casing Diameter in ThicknmWGaugc/ASTh4 Schell <br />O Steel O Plastic O Stainless Steel O Other <br />Grow( Seal Depth ft _ O Neat Cement (94 lb bag/ 5-10 gat waaer) <br />O Sand Ccu m sack mrs / 7 gal water <br />1 O Bentonite (20% solids) O Manufacturer Spec % solids __ % <br />Name O Spas on File O Specs Submitted <br />Great Placement Methed O Pumped O Free Fall O Other <br />O Retardant! Accelerator (name) <br />PEDESTAL follow BY O Driller O Pump Contractor <br />❑ Olber-- --�-_____---------__ . <br />O Concrete Pedestal Dimensions: Width_ R Length <br />Thick in O Christy Bos O Stove Pi <br />Pumpubmcrsible turbine O Other HP <br />Pump Set ft Blanding Water Lead _ R <br />WELL DMRUCfi n O Open f3oflom O Gravrl Pack O Uneased <br />O Other _ <br />Well Diameter_ in Total Depth ft Dc* to Water <br />_ ft O Casing to be Perforated from _T R to _ ft <br />Sealing Material O Neat Cement (941b bag / 5-10 gal water) O Sand Cement_ <br />-__-_sack mix 17 gal water O Bentonite PeUcas <br />O Bentonite (201/. solids) O Manufacturer Spa % sobs _ % <br />Name __ O Specs on file O Specs Submitted <br />Placement Method O Punyed O Free Fall O Other <br />. O Complete with Mushroom Cap ft below grade <br />O Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES A -ND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WIT13 UIE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM LV COMPLIANCE WITH ALL <br />WORKEILS COJ <br />1101'R AM *t%( -F NOT!; <br />SIGN TITLE Gw /V� DATE <br />Application Accepted By. <br />Grow Inspection By. <br />Pump Inspection By <br />Destruction Inspection By <br />DateN mace <br />Area Y /�L Employee ID# <br />O SPECIAL Well Permit <br />0 WAIYERReceived <br />Constructed Well Depth <br />R gY41, <br />FcF�VF� <br />JUN <br />do 19'4018 <br />ti oSMFN�UNTy <br />EpgRT��ryT <br />R <br />thD 43-02-0Ub WI:B <br />9/11/2007 <br />well rennin and uecraanaa.aa: <br />