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r) WELL/PUMP PET'" dT }J� SAN JOAQUIN CO. :ENVIRONMENTAL HEALTH DEPARTMENT .J4EWEBER AVE3"FL-STOCKTONCA 95202 - (2119)468-3420 NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED z q ary /� J � onOB ADDRESS IJ• 5 Z 9-V Y h1SDIJ FQ CITY121P " 0 2I 1tc�Fs CROSSSTREET c APN D - OiJ PARCEL SIZE Jw�LAND USE APPLICATION# kfk� OwNER NAME �KJ �J�,� �/ E� /��. 7 J� PHOQNE t OWNLRADDRESS O V �Q CITYISTATFJZIP /L l/ ONS cogT53(04 r� CONTRACTOR NEIL n-,�p�Sd� ,�- A5sso[.,�/�/n IM V �P/H•O�NE �� ^(Sr { - SUBCONCONTRATRACTOR TOR RACTORADDRESS OZ /� C. CITY/STATE/ZIP WQ '/52 Q A{1 3g 46 t SUBCONTRACTOR ' PHONE SUBCONTRACTOR ADDRESS C[TVtSTATPJZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER &VO EXPIRATION DATE d Q bb& GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑pomes[idPrivate ❑Irrigation/Agricultural 17 Industrial 0 Water Quality Monitoring Soil Sampling/Characterization ❑Public Water Syystem ame um r n + tcdiFTercm from Owner: aver ysin" n�ac+ ame or "e TYPEOF WORK Q New Well ❑Replacement Weil 0 Well Alteration/Mod ❑'fication 17 Test Hole ❑Other D Monitoring Well(S) 1 of Welis 316-ii Hoting(s)= R°f bO""✓ p ar6°ring Geotechnical ❑Well Destruction ❑Out-Of-Service Well Q Out-Of-Service Well Renewal ❑New Pump Q Pump Replacement Q Pump Repair ❑Cross-Connection R alt y WELL CONSTRHCITON v i Drilling Method ❑Mud Rotary ❑Air Rotary )(Auger ❑Cable Tool ❑Push Point 0 Other Proposed Well Depth f `f 5 t I eP ft Excavation —in diameter 13 Open Bottom U Gravel Pack/Gravel Size in diameter Q Conductor Casing in diameter ! Conductor Casing Depth ft Wel!Casing Diameter in Thickness/Gauge/ASTM Schell O Steel Q Plastic 0 Stainless Steel 17 Other O, i Crum Seal Depth („ P ft Q Neat Cement(9416 hag/5-logal water) ❑Sand Cement sack mix 17 gal water Q Bentonite(20%solids) LN l7 Manufacturer Spec%solids % Name ❑Specs on Fiie ❑Specs Submitted Grout Placement Method ❑Pumped Q Free Fall ❑Other ❑Retardant/Accelerator(name) -1) ' PEDESTAL installed By ❑Driller 6 Pump Contractor Q Other Q Concrete Pedestal Dimensions: Width_ ft Length ft Thick in Q Christy Box El Stove Pipe PUMP ❑Submersible Q Turbine ❑Other HP Pump Set R Standing Water Level ft I!l WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack Q Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft Q Casing to be Perforated from ft to ft Sealing Material Q Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack m&/7 gal water ,Bentonite Pellets Q Rentonite(20%solids) Q Manufacturer Spec%solids °/ Name l CG IA)4 SQ Specs on File Q Specs Submitted Placement Method ❑Pumped Q Free Fall ❑Other /F . ��- p ❑Complete with Mushroom NQ [•Cap fl below grade ❑Complete to Existing Surface Pad b } 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1 JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS y CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL l-- WORKERS CO ENSAT[pN LAW P 1 UM 24 HOUR ADVANCE NOTICE REQUIRED FOR[NSPECTfONS h t SIGNED DATE D IJ 12 !~ fE$rr5nt '.d -rtdLl3d 1 i ac lSANj 7 r DEPARTMENT USE NLY �`C7[- ONAq- k ._. Application Accepted By Date 2,C 6 Area_- ,,� Ploy I Grout Inspection By Date ❑ SPECIAL Well Permit Ji1 "r Pump Inspection B Date 13 WAIVER Received 1 Destruction Inspecti By Date/�o O s Constructed We[I Depth ft + COMMENTS r/%,-,-- '�s� +�!c7 y i. J'6�L!-i�C _icy✓ o•Y� i-+r�t•,�: sr-� { .+' PE Sc Received Che Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Wel!ID# 4a72, ISO X30 EHD 47-02-006 1 12/2M007 MASTRR W R WELL PERMIT