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r _ p . �1 SAN JOAQUIN COUNTY ENVIRONMENTAL P�EALTH:bEP FELLRWT i V Mp pE r 3.04 E WEBER A1r-1"%FL STOCKTON CA 95202 ,{209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 'INSPECTIONS, A /} } EhrhRE&I YEAR FROM DATE ISSUED CIFYI7,IP .IrC5` .� CROSS STREET ry� + fir: �- APN. "�G. ~ PARCEL SIZE LAND USE APPLICATION# tv OWNER NAME �j M OWNER ADDRESS ,V PHONE q — f✓6 CITY/STATE/ZIP1\01 CONTRACTOR , PHONE. 0 7 CONTRACTOR ADDRESS - I CITYISTATE41P SUBCONTRACTOR PHO SUBCONTRACTOR ADDRESS CITY/STATE/ZIP '- LICENSE - ❑C-57 R C-61, ❑D-09 ❑Ot er NUMEXPIRATION.D BER- ATE GEOGRAP14ICA4INPORMATION- Coordinate X y Township Range •Section t INTENDED USE [7 Domestic/Private rrigation/Ag cultural 13 Industria] ❑Water.Quality Monitoring ❑Soil Sam li❑Public Water System n C_ haracterization i If different from Owner: - -ter ystemame - I ontact ame or one.: um er TYPE OF WORK p New Well ❑Replacement We]]:- ❑Well Alteration/Modification. ❑Test Hole ❑Other ❑Monitoring Well(s) of well's ❑Soil Boring(s) t!of boring q ar-borings ❑Geoteehnical ❑Well Destruction v0w*f-Service Well ❑put Of-Service Well Renewal ❑New Pum ❑Pum 'R lacement um Re air [].Cross-Connection Re air WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑Air Rotary. ❑Auger ❑Gable Tool O Push Point.' ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom _ ❑Grave l Pack/GravelSizein.'diarrieter. ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing, Diameter in Thickness/GaugeJASTM Sclied ❑.Steel 17 Plastic ` :❑Stainless Steel;..% E7.Other Grout Seal Depth ft ❑Neat Cement(94 I6 hag/3 16gal'water) 0 Sand Cement sack mcx l.7 gal water W Bentonite(20.0/o.solids) ❑Manufacturer Spec°j°solids % Name ❑Specs on File ❑Specs Submitted f Grout PlacementMethod ❑Pumped ❑Free Fall ❑Other ❑Retardant/.Accelerator(name)= e I PEDESTAL" Installed By ❑Driller ❑Pump Contractor. ❑Other .❑Concrete Pedestal Ditiiensions:. 'Width ft, Length ft Thick in ❑Christy Bax Cl Stovc Pipe PUMP p Submersible Turbine ❑•Other HP , Pump Setft . Standing Water.Level :..42 ft Wil, WELL DESTRUCTION ❑Open Bottom Q Gravel Pack El Uncased ❑Other Wdll Diameter in Total Depth � Depth to Water' ft El Casing to be Perforated from ft to rt Sealing Material ❑Neat Cement(94 lb hag/5-10 gal water) E]Sand Cement sack mix 1,7 gal water ❑Bentonite Pellets f "�❑'He to onite`(20% 61ids) "E7 lvlanufa'eturer'Spec%a-s"o[ids� - % ''Name == -•❑Specs ots Rile Q Specs Stibmit e�d Placement Method. ❑Pumped.: ❑,Free Fall C]Other ❑Complete,with.Mushrmh.Cap ft below grade'. ❑'Complete to Exiting Suiface Pad , I HEREBY,CERTIFY:THAT I-HAVE PREPARED THIS APPLYCATION:AND THAT THE WORK,WILL BE DONE:IN ACCORDANCE..WITH`SAN JOAQUIN 'COUNTY ORI3INANCES, STATE LAWS,AND.RULES AND REGULATIONS. .1-ALSO.CERTIFY THAT MY REQUIRED bifkNSE IS' CURRENT AND ACTIVE WITH THt CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN:COMPLIANCE',WITH ALL WORKERS COMPENSATION LAWS: [MUM 24 HOUR ADVANCE NOTICE.REQUIRED FUR INSPECTIONS: I SIGNED-, rri ," TITLE {,'ISQ DATE 0 ./ 5�04:- . 07 r �5 RN JOA - r I i 11 N OI I :Ll IVIF ONE TA EAR:M [ f DEPARTMENT USE ONLY J Application Accepted By -Date Area Z f (p Employee ID#. Groutanspection By Date ❑ SPE W g _ „.__ [IAL . ell P.ermlt. Pump Inspection By -Date ❑- WAIVER Received a Destruction Inspection By Date Constructed-Weil Depth+ ft ` COMMENTS PE SC Received Check# Amount Date r.Perrnit/ Invoice# Well ID# Codes Info B as mitted Service Re Rest#: EHD 43-02.001 - -' - - - 1212=003 MASTER WATER WELL PERMIT i .. : r '