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y� WELL/PUMP PERMIT S,tv JUApUIN.Tft'§T}'ENV1RONN1F:NTAI.IIEA1-TII DEPARTNIEN-1' r 304 E W1211E14 Avl:3"'Irl,-SI'OCKTON CA 9.520 1)4(,9-3420 NON-RI;hUNDAli1,E PM;RI111TA1,1.(209)9N., F(IR 1'%SPF:('l'IO.NS EXPIRES I YEAR FROM D SUED JOBADDRLSS ''Clr C� Crrr�Irixu CROSS STREET APIC/] `(_/FV In�� Li �p , OWNERiNAME .li /'n..'olc`f j�R/ _ - _ P11oNt: OWNER ADDRESSCITY �] ISTATEIZIP CONTRACTOR c4,/1C "�t i4dci- - ,.- v C PFIONE6-C CONTRACTOR AbnRE:551 0,7;J) ,r(,`=-, / (� •7 l CITYISTATEIZIP ry C* SUBCONTRACTOR $UDCOS'l'RAC70R + �[//'C�/nJ!"( (Lr�` c• PIIONF SUDCONTRACTORADDRUS L�` � �Yerl .2,2 r S/ �C '�(1�I -5-C ' CITYIS[7?ATE7ZIP{-✓C T LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMDER��-CT/�� EXPIRA'T'ION DATE f' � � y GEOGRAPHICAL INFORMATION; Coordinates X Y Township>= Range C,e? L- SCCflor�a 1NTENbEb USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sampiiug/cumctCfizalion ❑Public Water System IfdiRerent from Owner. ager ystem arae mlau ameor one vm cr TYPE OF WORK ©New Well ❑Replacement Well ❑Well Alteration/Moi ificalion 0 Test l tole 17 Other MDnilOnng Well(s)lfJ_j� nomberafwells nub—fhori,g, lC21 mbof bings❑Sail Boring(s) 0Gcolechn ❑Well Destruction ❑Out-Of-Service Well D Out-Of-Servicc Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ugcr ❑Cable Tool ❑Push Point ❑Other Proposed Well DLpth j Z) --A Eixcavalion M in diameter ❑Open Iloltum AGravel Pack/Gravel Size /.�_io diameter m ❑Conductor Casing in dtamctcr / Conductor Casing Depth 11 Well Casing Diameter C in Thickness/GaugeIASTM Sched 7y 6 Steel ,Plastic ❑Stainless Steel ❑Other Crtlut Seal Deplh 40 „li / eat Cement(94!h hag/5-10 gal wurcr) ID Sand Cement such mix/7 gal water ❑Ileruonite(20%solids) ❑”Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Crout Placement Method ❑Pumped -rce Fall ❑Other ©Retardant/Accelerator(name) PEDESTAL Installed By 'SiP)nller D Pump Contractor ❑Other Wonereie Pedestal Dimensions: Width ft Length �Lfl Thick. -!!;K in ❑Christy$ox *s(ove Pipe PUMP ❑Submersible O Turbine ❑Other HP Pump Se! fl Standing Water Level n WELL DESTRUCTLON ❑Open Bottom ❑Gravel Pack Q Uncased ❑Other Well Diameter in Total Depth it Depth to Water R ❑Casing to be Perforated from R to It Sealing Material D Neat Cement(94 lh hug/5-70 gal wider) ❑Sand Cement ,encu aria l7 gal water CI Bentonile Pellets D Denlonite(20%solids) D Manufacturer Spec:%solids % Name ❑Specs on file ❑Specs Subnuned Placement Method ❑Pumped CI Free Fall ❑Other _ ❑Complete with Mushnrom Cap 11 below grade ❑Comptek In iixisting Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE, IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MININU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLFASE CALL(209)953-7697 SIGNED TITLE ��! � `[.�J• DATE c 0 i DEPARTMENT l45 ONL Application Accepted By Date Area Employee ED# %7 y Grout Inspection By Date 6 ❑ SPECIAL Well Permit Pump Inspection Ily Date 13 WAIVER ReeCIYCd R Destruction Ins�R7ectian By Date lCo grueted well Depth 3 p rt COMMENTS "{A}S�L� t G dr-Lf GSS : ��SZ� Jl e-'�th.0y� 1C�. PE SC I Received Check#/ Amount Date Permill4 Invoice4 "'ellID4 Codes Info B Cash Remitted Service Request 9 laa7 1 a "1 EHD 43-02-006 MASTER WATER WEIA PFRMIT