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WELL!PUMP PERMIT Ir SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IN EAST MAIN STREET-STOCKTON CA95202-(269)46&3426 • NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED • JOB ADDRESS _a/7� �!t-�e1icfi�lL fzl� CrrYrIAP CROSS STREET _�!0 PARCEL SIZE OWNER NAME �ON/(� /�jL( S�jJ/� /! — _ I T P[fOlnE�,�J�LP�7— OWNERADDRESS 2 Ze Al,A /�'^��uG,/��fCIITYI�STATEILIP Ae 1 ,/yy'�Cy�7r�� CONTRACTOR L_(m��/ `l UW ��jG��L�i /��/ u`/�� /7/ ,Z/�/ / �/JyS �j CONTRACTOR ADDRESS O s%!!/ �"� CITY/STATE/I1► /'�L�V J�/G�`/V� / ✓�✓ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS _ CITYISTATEMP Q `� LICENSE ❑C-57 C-61 ❑D-09 ❑Other NVMOER I EXPIRATION DATE GEoGRAPHICAI.INFoRxLATIoN: Coordinates X Y Townsb* Range Section INTENDED USE r/Private ❑Imption/Agricultural ❑Industria! ❑Water Quality Monittxing ❑Soil Samplingifhamcierr<ation ^ C� OT'abllc Water$ystetq_ ff dimaead Gam Owen Ware Syuadn Wm< Con`x Nanm n Pb—YuaBe' IN FE OF WORK ❑New Well Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other-- 0 ther _❑Monitoring We1Ns) -`bv f'd" ❑Soil Borings) es' ❑Geoteehnicat aanbQoftwxiogz ❑Well Destruction ❑Out-Of-Service Well ❑Out-0f-Scrvice Well Renewal ~ ❑New Pu R t ❑Pump Repair ❑Cross-Connection Repair WELLCON Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot `❑Push Point ❑Other Proposed Well Depth it Excavation in diameter ❑Open Bondml ❑Gravel Pack/Gravel Sire in diameter ❑Conductor Casing m diameter I Conductor Casing Depth R Well CaAng Diameter in Thick..s/GauWASTM Sehed ❑Steel ❑PIMc ❑Stainless Steel ❑Other Grout Seal Depth It_ ❑Neat Cement(94/b Lag/5-10 gal ware) ❑Sand Cement suck mix/7 gni water ❑Bentonite(20ai solids) ❑Manufacturer Spec%solids__% Name ❑Spens on File ❑Specs Submitted Grout Placement Methed ❑Pumped ❑Free Fall ❑Other ❑Retardant i Accelerator(name) PEDESTAL installed By, ❑Driller ❑Pump Contractor ❑Other_. ❑Concrete Pedestal Dhawasioes: Width fl Length_ft Thick in ❑Christy Boa ❑Stdn"e PUMP mersibie ❑Turbine []Other— HP Pump Sct I't Stsading WaRY Level It WELL DESTRUCTION ❑Open Bottom O Gravel Pack ❑Uncaud ❑Other _ Well D'iamefer__in Total Depth ft Depth to Water _—It ❑Casing to be Perforated Item_ R to _ It Seaft Material ❑Neu Cement(941b bag/5-10 gal wmer) ❑Sand Cement____sack mix/7 gal water ❑Bentoouc Pellets ❑Bentonite(26•/solids) ❑Manufacturer Spec%solids—% Name-- — ❑Specs on File ❑Specs Submitted w�� 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 LV ACCORDANCE WITH SAN V ED JOAQUINN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY"REQUIRED LICENSE p�� CURREN-f AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN LV COMPLIANCE WTTH A' WORKERS COMPENS, N LAWS. ?018 I'M 24 MOUR %DV X%CF NO'I t: IRF_D FOR INSPFCTION, Tom/ �Jto,A tt,/� 10 SM.. TITLE !/!//////f�/'�.-� DATE r/ c'�✓/RpA,I� C01lAi7-V t DCr11pgA7RENTl�,TI AIN 'OfFf 10 ARTMENTU E N — —! Application Accepted ByDate Area F.Tloyee ID# Grout Inspection By Dau SPECIAL Weil Permit Pump mv-i-BY , Date 0 WAIVER Received Destruction Inspection By Date Constructed Wen Depth R CONL14EN IS CPPE Info SC Received ftA2611 �ed Date Perlow Best# invoice# Wen M# EHD 43-02-006 WEB Well Pemut and DeclarzoonAm 9/11/2007