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'i WELL/PUMP PERMIT Zt)2 C SAN JOAQUIN COU]vfY ENvrRONMENTAL F.DEPARTMENT 304 E WEmER AVE.1`"- TOCKTON CA 95202 - (209)4(5-34 NON-REFUNDABLE PPFRMI p�trY CALL 1209)9$3.7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUE O [Fly JOB ADDRESS -7 So z� l�_.�� C[TV1ZiP 1 r�� r/I 1�� > CROSS STREET Y All 003- PARCEL SIZE me OWNER NAmr. CJ PHUNE -4 � 1 -0013_ i OWNER ADDRES4 CITYISTA-mlzip y � CONTRACTOR � �4 ) _ �1 ` Yy _ �7 _tJ Y Nit I CONTRACTOR ADDRESS CSI CITvfSTwT"'I' SUBCONTRACTOR"' PHONE I SubcO�.NTRACTOR ADDRESS CITYISTA t'ElL1 P LICENSE QC-57 C-61 OD-0 koIhcr l�1.I� �>2 I NumDeR EXPIRATION DATL �l 1 GEOGRAPHICAL INFORMATION: Clwrdfaates X Y Township_ Range Section INTENDED USE ❑Domestielprivale '%IrrigalionfAericultural ❑Industrial Q Water Quality Monitoring ❑Soil SamplinglCharacterizabon ❑Public Water System Ifdffrreal From Owner: nes ysum eme —Zon�actt.-o� art an er TYPE OF WORE: 17 New Well Cl Replacement We]) O Well Alteration/Modification ❑Test hole ❑Other numberofwrlla numberufli xings number of borings ❑Monito$ng Wtll{s) _ ❑Soil Boring(g) ❑Geotechnical ❑Well Destruction ❑Out-ofService Well ❑Out-Cf-Servim Well Renewal ❑New Pum *Purop R fe,-.omen[ ❑Pump Repair ❑Cross-Connection Repair } WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Coble Tool C Push Point ❑Other ` E Proposed Weil Depth fl Excavation In diameter ❑Opcn Bottom ❑Gravel Pack 1 Gravel Size in diameter I ❑Conductor Casing in diameter 1 Conductor Casing Depth __It Well Casing Diameter_0 Thiekness1G1UgdASTl,4 Schcd ❑Siecl Cl Plastic ❑Stainless Steel ❑Other Grout Seal Depth_ft ❑Neat Cement('94 1h hag/5-70 gal»neer) Cl Sand Cement ,sack mir/7 gal water Q Benntnite(2Q%soWs) 0 Atanufaerurer Spam%solids_% Name_ ❑Spccu un File ❑Specs Submitted Grout Placement Method O Pumped f]Free Fall ❑Other_ ❑Retardant 1 Accelerator(name) PEDESTAL Installed k ❑Driller C3 Pump CDnrraCtnr ❑Other ❑Concrete Pedestal Dimensions: Width fl Lengrh fl Thick in ❑Christy Box Cl Stove Pipe PUMP Submcrsibie 0Turbine 0Other HP Pump Set fl Standing Water Level R i WEU.DESTRUCTION ❑Open Bottom ❑Gravel Pack 0 Lirmsed fJ Other Well Diameter_in Total Depth fl Depth to Water fl ❑Casing to be Perforated from tl to f3 Sealing Material 17 Neat Cement(44Th h gl5-10 gat tearer) 0 Sand Cement suck rnix 1'7 gal water ❑Bentonite Pellets ❑Bentonite(201A solids) ❑Manufacturer Spec%solids J__% Name_ ❑Spec on Pile ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other,_ ❑Complete with Meshmortt Cap 11 below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THr1T THE WORK WILD BE 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPEINS4TION I.AWS- INIMU 4 HO ADV NC NOTICE REQUIRED FOR I SP-CTTIONS—PLEASE CALL(209)9 3.7697�/]may;�� p s SIGNED $1TLESC 7 1 �J3A/[�t1/ SA J Ai in CO ',T DEPART,HE�tiT SE ONLY - .. v f Application Accepted By DEPARTMENT batt —11 -0.3 Arca d I Empioyec l6k� y - ❑ SPECIAL Well Permit Grout fnsptennn By Date Pump Insprtion By��a A c r.- u�- Date 7=sl=s"U-I ❑ WAI VER Reeeived Destruction Inspection By__j Date Constructed Well Depth It COMMENTS Ze-fCJftl'1'll'' 'dl I 'Ll' PE SC Received Charh/11 Amount ate lnvolee# Well PEW odes Info B Remitted Service Ar nest# EHD43-02-ON MASTER WATER WELL PERMIT I 121612002