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I WELL / PUMP PERMIT SANFIdAQUIN COUNTY ENVIRONMENTAL HEALTH DE, ,'MENT 304 E WEBER, .Rn FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209) 9'530-7697 FOR INSPECTIONS EXPIRES I YEAR/FFRJr}tOM /D/�fAT�E ISSUED LP JOB ADDRESS W� N • • / 1•IA u L CITY/ZIP 1Wf`� 11 , a%o I y ftcLOCROSS STREET C APN 09- 4 l b 3 ( PARCEL SIZE A OwNERNAME '/ S PHONE u OWNER ADDRESS CITY/STATE/ZIP {/�]� 2 ' r CONTRACTOR I-1 I I n2rrcr C�.jo,�s�� y c.-�hj PHONE � �/1��/�j��/'U/ ��I�rtyl�GU�LI CONTRACTOR ADDRESS (JUI�;J 21'�L(.�Yil I�JI VI�C_. CITY/STATE/ZIP W Sac910-4q3-44-go YU.fY Ii/M'f^fk\ .�///I��y7,`(./1J�I)O"7I SUBCONTRACTORj)KPHONE 10- /1f^,3— r�'�`e�ot 401 S(UUB{/(CSONNNT��R/-]ArjC�$IT�ORRAADDDRE�/IS�S�I��q� I A Z CITY/STATE/ZIP 'ElEg ws PLS LICENBE'" LP / LJ 1:-61 ❑D-09 Other T I� G NUMBER`-' ' EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Sail Sampling/Characterization ❑Public Water System Ifdifferent from U..n Water System Name Contact Nmue or Phone.Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole Cher L �� ❑Monitoring Well(s) numberofwells ❑Soil Boring(s) numberofborings ❑Geotechnical number ofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELLCONSTRUCTION Method 10 nrlNp OTjr>•..I�n � bee . Drilling Method ❑Mud Rotary ❑Air Rotary 13 Auger ❑Cable Tool ❑Push Point `Other ll l ll� It.+�(,(J(_, UL Proposed Well Depth If Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib hag 15-10 gal wafer) ❑Sand Cement .sack mix/7 gal water N ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor g(Other 1(jLjAQi ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine Other jd(2,14f., HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Loosed ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94/b hag/5-10ga/water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitte Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad xa I HEREBY CERTIFY THAT I 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 AV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENS ION LAWS. MINI U DV CE NOT D FOR SP CTI(/q NNS(--frpLEASE CALL(209)9 -7 97 SIGNED TITLE =/ 1 V C�1 DATE U 911 nj O IN OAFT T p l FF 02. DEPARTMENT USEJON gnj Application Accepted By Date W�j,Q Area Employee ID Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received eck# Amount Date Permit/ Invoice# Well ID# Codes Info BY ash Remitted Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002