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✓1�7 �+t�, r ,c"I='1Prelriew; (54�- Cr !'ewt) P-aAl A WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DELENT 304 E WEBER A•"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT *LL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED L, JOB ADDRESS '� .1 f 1..!`. _/3..1 i2!_ /G..:.<l.� CITY/ZIP "7-�,T"1��. }r� P'41 D CROSS STREETt''r"•'�^ APN 4 FS / U / PARCEL SIZE ~ /�G,rz�3 X /J� ,/ OWNER NAVE ()A'1,.a COLI n`iPc�f) PHONE .>`r•IF! OWNER ADDRESS -� tt Isi1"r CITY/STATE/ZIP CONTRACTOR I-f C.-L er��r'L„c..r}+=B-I-z- 1;J C.- PHONE y-,21)*7 ^ E/4 ; CONTRACTOR ADDRESS u? C i';'`✓ft 1 �. _ '51 Pi-16 7 CITY/STATE/ZIP `5*r-C.r�-'Ts:.-I CA SUBCONTRACTOR ryC C `Z^ - PHONE ri SUBCONTRACTOR ADDRESS CITY/STATE/ZIP -+-M1"�-a-T*�^J LICENSE rb C-57 ❑C-61 ❑D-09 ❑Other NUMBER 51 2.-Z.L.'D EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township 3 5 Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural 'l ❑Industrial Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other 16 41 number of wells number of borings number of borings Monitoring Wells) .,- El Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth (4, ft Excavation t in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASTM Sched N c;' +9Jc ❑Steel 4 Plastic ❑Stainless Steel ❑Other .a Grout Seal Depth 14 ir ft /N,Neat Cement(94 1h hug/5-10 gal water) ❑Sand Cement .cock mix/7 gal water a ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method �Piimped ❑Free Fall ❑Otheryl'�int +--W •+ 9,Retardant/Accelerator(name) PEDESTAL Installed By A Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length .2- ft Thick in ❑Christy Box kstove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other V Well Diameter in Total Depth __ ft Depth to Water _ft ❑Casing to be Perforated from ft to tt 'f+ Sealing Material ❑Neat Cement(94 lb hag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted 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 IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSAI-10. 1 AW Mllyl`MU 2 �ti I�ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-76 7 SIGNED ! TITLE IYtE C',u��-e DATE / a. � i 1 � 4� .7e IN - f, 11 E.0 �7 A J AQ IN COLIN HE LT Y ) tNVtRO 1 — -- �, k f , DEr RTMENT USE NLY a t' Application Accepted By Date 7 U 1 Area Employee ID# i Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By_ _ Date Constructed Well Depth ft COMMENTS f C7�r �ti'c t,trt�ll G Iv,t ��. uf� F✓a�.'�m¢r"?< Icfrt tL PE S Received �,y eck#/> Amount Date Pe,'m't/ `- In ice# Well ID# Codes Info • `B Remitted Service 'desift r ------------ EHD 43-02-006 MASTER WATER WELL PERMfr 12/6/2002