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„WELL / PUMP PERMIT I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 6604TMENT 304 E WEBEho/c 3”FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOHADDRESS :2,�073 CITY/ZIP > CROSSSTREET LA,1 ;Z, e,,,,J APN PARCELSIZE IA177 OWNER NAME G', PHONE 1;�.V-713 1 OWNERADDRESS ;Z307 3 L-JL__ CITY/STATE/ZIP R)paey , eA 9-PF-3 6 6 10 CONTRACTOR Ar4_5 Ke/t4.ailea PHONE ��&_Tys_k CONTRACTOR ADDRESS S CITY/STATEJZIP Z pa") CA SUBCONTRACTOR nV SUBCONTRACTOR ADDRESS CITY/STATE/ZIP F LICENSE 0 C-57 0 C-61 0 D-09 0 Other N U M B E R_6jk_��— Z— EXPIRATION DATE &,//Ili GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 13 Domestic/Private X1rrigati0n/AgriCUItUraI 13 Industrial 13 Water Quality Monitoring 0 Soil Sampling/Characteritation 13 Public Water Systern II'diffmatfounCumer: Wmr System No. Comact Nam or Phone Number TYPE OF WORK 0 Now Well 0 Replacement Well 0 Well Altemtion[Modification 13 Test Hole 0 Other 0 Monitoring Wells)_ ".be,of W.11, 0 Soil Boring(s) number ofbonnp 0 Gemechnical number of boomp 0 Well Destruction 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 13 New Pump KPump Replacement 0 Pump Repair 0 Cross-Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary 13 Air Rotary 0 Auger 0 Cable Too] 0 Push Point D Other Proposed Well Depth—ft Excavation in diameter 0 Open Bottom 13 Gravel Pack/Gravel Sim in diameter 0 Conductor Cuing in diameter / Conductor Casing Depth ft Well Casing Diameter—in "fbickness/Gauge/ASTM Sched 0 Steel 0 Plastic 13 Stainless Steel 13 Other Grout Seat Depth It 0 Neat Cement(94 lb bagl5-10 gal water) 0 Sand Cement sack mix/7 gal water 0 Bentonite(20%solids) 0 Manufacturer Spec%solids—% Name 0 Specs on File 0 Specs Submitted Grout Placement Method 0 Pumped 0 Free Fall 13 Other 13 Retardant/Accelerator(name) PEDESTAL Installed By 13 Driller 13 Pump Contractor 0 Other 13 Concrete Pedestal Dimensions: Width ft Lcngth_ft Thick in 0 Christy Box 0 Stove Pipe Pump )"ubmersible 0 Turbine M Other HP Pump Set __6 3 ft Standing Water Level _/za� ft WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 13 Uncased 0 Other Well Diameter in Total Depth_ft Depth to Water_ft 0 Cuing to be Perforated from ft to ft Sealing Material 0 Nest Cement(94 lb bagl5-10 gal water) 0 Sand Cement sack mix/7 gal water 0 Bentonite Pellets 0 Bentonite(20%.solids) 0 Manufacturer Spec;0/solids—% Name 0 Specs on File 0 Specs Submitted Placement Method 0 Pumped 13 Free Fall 13 Other 0 Complete with Mushroom Cap_ft below grade 13 Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIO S. A MIN17M —P ?�41!PdR ADVANCE NOTICE REQUIRED FO ',SPECTIONS LEASE CALL(209)953-7697 4 SIGNED TITLE 'or a DATE P Ap 1v A I RF=("EL it =y I I h*,, V., HIN LLI I )it kUL I- e PA TMFN _T F FFI T,I Df.C DEPA AR1 4LV Application Accepted By Date JI4-04�0- 03 A r ca Employee ID# .:ion By Date 13 SPECIAL Well Permit Grout Inspect Pump Inspection By Date 0 WAIVER Received Destruction Inspection By Constructed Well Depth ft COMMENTS PE SC Received eck# Amount Dfte Se"Permit/ Invoice# Well ID# Codes Info By as Remitted ice Request# q3-Me) 6VO-6 11AZZ216KOO'g or EHD 43-02-006 MASTER WATER WELL PERMIT 1216/2002