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BAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT WELL/PUMP PERMIT' 1866 East Hazelton Avenue-STOCKTON CA 95205.6232 - (209)468 NON-REFUNDABLE PERMIT CALL 209 953.76197 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSU Joe ADDRESS 27F19 F Qm_ RT iF clrr/zlP LINDEN CA 95236 _ CROSS STREET Ar CNFT_rriV RD APN 067-24-003 PARCEL SIZE 269.-, -AND USE APPLICATION# OWNERNAME EUGENE CAFESS'F PHONE 209_481 -595F OWNER ADDRESS $475 VAN AT T EN gr) CITY/STATE/ZIP GThrTi ra a 521 S CONTRACTOR Delta P11MR STO KTQN ARMATURR & -MOTOR ---Kg X311, 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP_ Stockton, CA 95203 _ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 11 LICENSE ❑ 0-57 79 C-61 0 0-09 ❑ Other NUMBER 72477$ EXPIRATION DATE 08/1.6 GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range_ Section INTENDED USE ❑ Domestic/Private CX1XIgatlon/Agricultural D Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization 0 Public Water System If different from Owner; a er ys am eme on ac eme ar one um er TYPE OF WORK 11New Well ❑ Replacement Well D Well Alteratlon/Modification 0 Other 0 Monitoring Well(s) #of wells 0 Sol Boring(s) 4 of bodngs ❑ Geotechnlcal #of bofings 0 Out-Of-Service Well 0 Out-Of-Servlce Well Renewal 0 Cross-Connectlon Repair 0 New P'ump O.Purnp Replacement Xump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other- Proposed Well Depth m ft Excavation In dlaeter D Open Bottom D Gravel Pack/Gravel Slze In dlamE D Conductor Casing In diameter / Conductor Casing Depth ft Well Casing Diameter_ In Thickness/Gauge/ASTM Schad ❑ Steel 0 Plastic 0 Stainless Steel 0 Other Grout Seal Depth ft ❑ Neat Cement(941b bag/6.10 go/Water) 0 Sand Cement sack m1x/7 gal WE ❑ Bentonite(20%solids) ❑ Other ' Grout Placement Method ❑ Pumped 13Free Fall 0 Other D Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other 0 Concrete Pedestal Dimensions:Width ft Length ft Thick n El Christy Box ❑ Stove Pipe PUMP tMiomerslble0 Turbine 13Other HP 6 n Pump Seta 9-- N'ft Standing Water Level � I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SF JOAQUIN COUNTY-ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT] AM IN COMPLIANCE WITH At WORKERS COMPENSATIO LAWS; UM 14 OUR ADVANCE NOTICE, REQUIRED FOR INSPECTIONS SIGNED, TITLE CEO �,`'� le DATE N(''fLL ' o �P, NOTE.Take HIGHWAY 26 PUMP/WEIs fatted �qqq( z L' approx.333.62 ft.from tllrt �iy '� EAST past the town of LINDEN,at rd. Escalon Bellota Rd.continua east on highway 361or about 3.5 miles s laawintlmlll on Lha North side of itNIL - tt: the highway. ` a (•' f i Li I - 4 `. N. /_ q ILL L 1/I 'F 3$ 1 ' Y J wINOMIu It � C f o �n �r DEPARTMENT USE ONLY Application Accepted By �'1 1�—J�— Date _ Area t 4 Employee ID# Grogt Inspection By Data SPECIAL Well Permit Pump Inspection By Date WAIVER Received Sell Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received a #/ Amount Permit/ Codes Info B s Remitted Date Service Re uest# Invoice# Well ID# A3%-J- o)' - z8o -+OLA/ -12-1G 52007533 EHD 4MO 8/04/08 WELL/PUMP PERMIT