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WELL/PUMP PERMIT Lau rr W,!�'A� SAN JdAQU IN COUNTYENVIRONNIENTALHF-ALTH DEPARTMENT 304E WEBER AVE 3"c IfLe STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS r-- m CITY/ZIP c CROS8 S-1'REET APN PARCELSIZE 1 '- OWNER NAME errn /Kf r(-1L�".�,'knV 1 'h �,y�PHH+O/NEE�,��/yV� OWNER ADDRESS ✓Ji7l� 1Vl). j'\ty ty'J - CITY/STATE/"ZIP (7 tJl'S..1U 114fT I ] _� CONTRACTOR1l 1�zzt2�T^�'11 PHONEg►1�-Cja'4 -&44 CONTRACTORADDRESS,, — "L JC.t 1r\rA t�(`I -*,e 7 17 CITY'/STATE/ZIP SUBCONTRACTORy}J4JYC..��] 1�11/��Q y�1,m SUBCONTRACTORADDRE:iS � V a l d`(lY �aY(n J CIT1YISTGATE//ZZIP LICENSE U-$7 ❑x'-61 ❑D-09 ❑Other NUMBER j l�J 1 LJ EXPIRATION DATE ll GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rarge Section I INTENDED USE ❑Domestic/Private ❑Irrigatiun»Agricultural Q Industrial ❑Water Quality Monitoring Soil Sampling/Characteninuon ❑Public Water Syy tem _ _ Vdiffaem fromwn Oer'. Warm yemm Name J' .uman amc orf unc Number } TYPE OF WORK ❑New Well O Replacement Well ❑Well AllerationWodiucation O Test Ilole ❑Other ❑Monitoring Well(s) "O1"p"of w-ens D<Dil Boring(s) _IQ_ numberof1"ria6s pGeotechnical ""^`h of parings ❑Well Destruction ❑Out-Of-Service Well QOut-Of-Service Well Renewal ❑New Pump ❑Pump Rtolacement ❑Pump Repair D Cross-Connection Repair WELL CONSTRUCTION � Drilling Method E)Mud Rotary (3 Air Rotary 6YAuger ❑Cable Tool Q Push Poin; El Other _ Proposed Well Depth_ V5 H Excavation— x in diameter ❑Open Bottom ❑Gravel Pack/Gravel Si2e—__in diameter ❑Conductor Casing in diameter / Conductor Casing Depth `11 Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth I t ft ❑Neat CCmenL(94 161arg/5-10 gu(wu(er) ❑Sand Cement tuck mix 17 gal water ❑Bentonite(20%solids) ❑Manulactum Spec%solids % Name— ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Widthfl Length R Thick in ❑Christy Bot O Stove Pipe i PUMP O Submersible 11 Turbine ❑Other__ HP_ Pump Sct A Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other_ Well Diameter in 'Total Depth ft Depth to Water Il Q Casing to be Perforated from tl to fl Sealing Material ❑Neat Cement(94th bug/J-JO gut wrrlerj ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets M ❑Bentonite(2D9/solids) ❑Manufacturer Spec%solids _% Name r ❑Specs oo Fiille,,�❑3 Specs Submitted Placement Method ❑Pumped 11 Free Fall G(Other j _f-)D � V-�Ckf111 -31 C,JA-h Ods (�1 ❑Complete with Mushrcom Cap fl below gradr, ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN m JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY TIiAT MY REQUIRED LICENSE 1S CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH AL1, f1t WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE vyREQUIRED FOR � IN��S+(�PECTIO-}NS to SIGNED (r_`e�� TITLE lJ\VAVM Y1;i l'—��fR.IP firs DAT'F, -_ O 7Z 2:4 00 Isr T u 1 TM S DEPARTMENT USE LY ��, /// L.�® [[(} Application Accepted By_ _ _ Date�_ -y Area / 1) Employee 1D# Grout Inspection By _ Date _ / ❑ SPECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received Destruction Insp�vI'p By Dale Constructed Well Depth It COMMENTS ebsei-k'e .J/e S G(ys ill, I c2�(P' s rvrd /s/ '&'--e Gtll fll G'Gt t77 z' LAttw ti4 Iz PE SC Amount Received Permit/ Codes lnl'o Remitted ash B ate Service Re nest$ Invoice p Well IDR 5e00zs`1000 EH 43-02-006 MASTER WATER WELL PERMIT