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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH' 'ARTMENT 304E WEBER -VE 3W'FL-STOCKTON CA 95202 - (209)46&3420 NON-REFUNDABLE PERMIT ''-wA CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED N_ r �I t r, ' (,p J08 ADDRESS `U I� Vy i jer UJ _ � CITY/ZIP CROSSSTREET LWit SoLra(hen� APN / 1 40 a]T�0 �9 T2�PnA RCEL SIZEIZA OWNER NAME ay n s+,,e kTr>� y LCckrhidt PHONE SfA OWNER ADDRESS L, (' CITY/STATE/ZIP CONTRACTOR If_NA-1-P'`��G-•rp-- PHONE ` 12C.�9- 9n (.,yr'L CONTRACTOR ADDRESS .LJ G. 1��\/(-�e c1T. CITY/STATFJZIP �IOCJ�O�\� A -IS2Dr SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/ST AT E/ZIP �f ( 11 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER ��7�G.,]Z EXPIRATION DATE j{-(31/Ol }( S GEOGRAPHICALINFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ,c ❑Public Water System IftiRervetfrom Owner: am System Nam Cannot No.or one um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Wells) numberofwells ❑Soil Boring(s) number ofborings I(Geotechnieal .L numberofborm, ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 3.T It Excavation L4—(a in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft ct- Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other T Grout Seal Depth ft ❑Neat Cement(941h hog/5-10gal water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Spms on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width }t Length_ft Thick in ❑Christy Bos ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tl Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from R to 0 Sealing Material ❑Neat Cement(94 lb tag15-10 gal water) ❑Sand Cement sack mix/7 gal water KBeenttom eeyPeetll�ets 1 �[,�7,�,. elkIL ❑Bentonite(20%solids) 13 Manufacturer Spec%solids % Name ❑Specs on FSTe ❑S s Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑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 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE .4hi1`f EnoQ Ate r- DATE �S/b[•a�03 l e e e --' 4✓ N� % L t W IFR O °' �' e ' L i t t t e lO N ily TK 71 I LII Hi TH VN SINN 0, fn1)p,�q�,r, '' DEPARTMENT USE ONLY p 3S- Application _ Application Accepted By J (LIA� `J`4t%7 t�`^ , Date S -' 1 -0 Area Z Employee ID# �0 J`s Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection ByC7r`'/-GCIDate Constructed Well Depth R COMMENTS 35'Ai At(= —.f/�/s'} PE SC Amount Check#/ ReceivedBY Service Re nDate Permit/est# Involve# WeI11D# Codes Info Remitted as 1 -L-3 03 37.Z EHD 43-02-006 MASTER WATER WELL PERMIT sn/zoo2