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REC <br />MAY <br />ENV'IIIONM <br />0h,Pll1 <br />WELL / PUMP PERMIT V_V/ I � <br />Sus JOAQUIN COUNTY ENyIRONMENTAL HEALTH DEPARTMENT 600 EAST MATH STREET - STOCKTON CA 95202 - (209) 468-3421 <br />INUIN-KEFUNDABLE rFAL`MII7T EXPIRES I YEAR FROM DATE ISSUED <br />Jog ADDRESS _ V_ �•�^%'&'13 '/ �CJrt,,,,.P <br />CROSS STREET `�I 1 AP__a�(�av _ PARCEL SIZE _ <br />OWNER N.&ME /%�Xn X�+ /� NE <br />OWNER ADDRESS _ ! V t� CMISTATEMP <br />CONTRACTOR Ag/7 PDONE <br />s.anNTMT <br />CDR ADDRESS /D / D _�, �_� CIT1/SI41TIZIP <br />SUBCONTRACTOR PDONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/7AP___ <br />LICENSE ❑ C-57 661 ❑ D-09 ❑ Other NvmnER ExpiluivO!1 DATE^lLl_Y <br />r:F11(:a AeN1r A1. dNFnQArATexM1e r`nnrdlQsw X v Te hln R.— S.1-flon <br />INTENDEDUSE ❑ Domestic/Privatc )rrigation'Agriculttual ❑ Industrial 13 Water Quality Moaiioring 13 Sod SamplmgiCharacicTitation <br />` ❑ PAbbc, Water System <br />ifdiff ul .OwneS Watt System.Name L'omacr name aPhno :lumber <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Moditicatitm ❑ Test Hole ❑ Other_ --- <br />❑ Monitoring Wei n..bc f_us ❑ Soil Boring(s) mm�ber ortwri,gs ❑ Geatechaieal "11O�uf txriogs <br />(] Well DcstnK-tion ❑ Out -0f --Service Well ❑ Out -Of -Service Well Renewal <br />WELL CONSTRL1 1 N <br />Dr0ling Mediad 0 Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Odtcr <br />Proposed Well Depth ft Excavation in diameter O Open Bottom ❑ Gravel Pack / Gravel Size in diameter <br />Cooductor Casing in diameter / Conductur Casing Depth fl <br />Wen Casing DTameter,le Thi:1mcswGmgWASTM Scholl ❑ Steel O Plastic ❑ Stainless Steel ❑ Other <br />Groat Seal Depth It ❑ Neat Cement (94 lb bag / 5-10 gat avW) ❑ Sand Cement sack mix / 7 gay wafer <br />O Bentonite (20% solids) O Manufacram Spec % solids % Name O Specs on File D Specs Submitted <br />Groot Phicement Meshed O Pumped O Frec Fall ❑ Other ❑ Retardant i Accelerator (tame) <br />PEDESTAL hastaRed By ❑ Driller ❑ Pump Contractor O Other_-_.- <br />❑ Concrete Pedestal Dimensions: Width _ ft Length_ it Thick in ❑ Christy Bax ❑ Som -e Pipe <br />PUMP ubmersible Turbine (3 Other _ HP _jQ Putnµt Set ti Standing Weser Lcvd . R <br />WELL DEsTRUCrt N O Open flonam ❑ Gray) Pack 0 Umwcd O Other _ <br />Well Diamctcr__ in Total Depth It Depth to Water it 13 Casing to be Perforated from ___ R to ft <br />Scaling Material ❑ Neat Cement (941h bag / 5-I0gal Bluer) ❑ Sand Cemrnt _wk mix 17 gal water O Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids 55 Name __ O Spccs on Filc ❑ Specs Submined <br />Placement Method ❑ Pumped ❑ Free Fall ❑ Other _ <br />❑ Complete with Mushmom Cap 11 below grade ❑ Complete to Existing Surface Pad <br />I <br />HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK RILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQULN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WI CALIFORNIA CONTRACTORS STATE LH�NSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C01 <br />I HOUR ADN NNOT!f'T' Rt.'ryi Italrn FnR 1\"I'f �* <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Destruction Inspection By <br />COMMENTS <br />Dam �-t U <br />Date <br />Date <br />Area _� Employee IDa <br />El SPECIAL Well Permit <br />O WAIVER Received <br />Constructed Well Depth <br />x <br />in <br />R84 yMF�T <br />CF�V�O <br />AN0 <br />Fiv�,°gQ�iN, ?018 <br />9Cly� pA z <br />Nr <br />It <br />EHD 43-02-006 WEB Well Pmmit and DecIvavon.doe <br />9/11/2007 <br />