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WELL/PUMP PERMIT '� � SM dOAQUUV COUNTY ENA'IRONMEISTAL Ttl Dr WELL 600 E.AsT MAIN STREET-STOCKTON CA 95202-(-09)469.4EYE— uART101ENTNEON-REFUNDABLEPEP-MIT r-tI1I(22091.9S3-160-1-srRll\tiP! �E7'X�/PIRES1YEARFROMDA'T�EISSSUEDry JOB ADDRESS SJ 1 //�� S��„(�I Y`--7 INC>�'l• c/rl/t11/J�7IP.]1(Y..�� 'SS L�L�J/��I t�ss7 CROs.SSrREET C44n" I t5.. — L-A N APN_O ' [_(( v PAMML SIZE V kG�"Or 1%&tom kLC— PttorE wog -�4cof30 SP OWNER V.AME /� '�f ,� �/� A` Q .7 OWNER ADDRESS SS-t 91` ' 5o e.jt/a1z I Y12--&-re,VGH�`VL-0 /�CIrrY/STAT/�P/Z�I► �pC.�I Vm f �`AL CONTRACTOR / I"`�r-s .`j 1/\Je i Y L...�LJ E L J F"t cc/ 1 • 4�. !PRONE��- �J G?-2a 7 O (�^ CONTRACTOR ADDRPJS 10-7 K/ S. 14W sj 2.ko CITY/STA WWW ' Yf��_S'�4tJi CCt`1 Z Y SUBCONTRACTOR PRONE SUBCONTRACTOR ADDRESS _ CI'IY/ST.ATE/ZIP 9 LICENs2 ❑C-.57 C-61 ❑D4)9 0 Other NUMBER V�� EXPIRATION DATE � a O GEOGRAPIDCALINtORntATIOet: Coordinates X Y Township_ Range Section INTENDED Use Dovteatir/Plivate ❑I trigation/Agricuhural 0Infilgrial 0 Water Quality Monitoring ❑Soil Sampling/CharacteriUsuion /0N11 blDeit WSW System__-..--- - — — ---- /I If d. rcnt 6mo Owrkr: Water Sysmm N— Camara NNa—ur Pbnne Number PA TYPE OP WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other __ ____ EFCeiv ❑Monitoring Well(s) numbarofwdls ❑Soil Boring(s) nurakrofborings OGe< 1mical — numbcrofburirpe 0Well Destruction ❑Out-0f--Service Well ❑OAit-Of-Service Well Renewal A y ^ E3' I' Pu Pu Replacement ❑Pum Rc it O Cross-Conocction R /�j! L qty WELL CONSTRUCTION S/{ 2®1Y Drilling Method ❑Mud Rotary 0 Air Rotary 13 Auger 0 Cable Tool 0 Push Point ❑Other _.__ JOA QUIN Proposed well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack/Gravel Sae in diapyttc� I Rotgf OUN r, 0 Conductor Casing in diameter / Conductor Casing Depth ft �H �l pEP NT'AL Well Casing Diameter in ThicknesdOauge/ASTM Sched __ 0 Steel 0 Plastic 0 Stainless Steel 0 Other A'QTME,, Grout Seal Depth R ❑Neat Cement(94 lb bag/540gal Baster) ❑Sand Cement sack astir 17 gal water ❑Bentonite(200/a solids) ❑Manufacturer Spec%solids _% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped 0 Free Fall ❑Other 0 Retardant/Accelerator(same) PEDESTAL Installed By ❑Driller Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Wi ft Length_ft Thick i 0 Christy Box ❑Steve Pipe PUMP Sub—ible 0 Turbine ❑Other HP Pump Set It Standing Water Level R WELL.DESTRUCTION ❑Open Bottom 0 Gravel Pack ❑Uwascd ❑Other Well Diameter__in Total Depth ft Depth to Water R ❑Casing to be Perforated from R to ft Sealing Material 0 Neat Cement(94 lb bag/5-10gal water) ❑Sand Cement_ sack ma/7 gal water 0 Bentonite Pellets ❑Bentonite(200/,solids) 0 Manufacturer Spec%solids_.% Name 0 Specs on File 0 Specs Submitted Placement Method 0 Pumped 0 Free Fail 0 Other ❑Complete with Mushroom Cap ft below grade ❑Cwspkte 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I iH 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED_ -----_—__.-- -- TITLE va"^r' _-- DA 1, /_ PA,RTMENj&UPNLY Application Accepted By Date _ Area Employee ID#_ GroutlnspectionBy �,t�', — Date �t ❑ SPECIAI.WellPermit Pump Inspection By ��d&ixY nett _J d ❑ WAIVER Received Destruction Ins"on By Dote Constructed Well Depth It COMMENTSL taw �A��_�M�CLN 2 �O L)tr\ ---—--_ PE SC Received Ch--koAmount Perstit/ — Coll Info emftted Date Service �y tovoicep WeIIID# •2�-�A P FHD 43-024X)6 WEB Well Permit and Dmlaranmt.doc 9/11/2007 0