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P - -sem q15 - WELL / PUMP PERMIT S k.Z ,N JOAQUIN COUNTY ENVIRONMENTAL HEALTH 06wfRTMENT 304E WEBER eSen FL-STOCKTON CA 95202 - (209)46&3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �y.�r p.� ` .r JOB ADDRESS J 7&7 6u�.s6y A15C• CITY/ZIP a p.,� v CROSS STREET G �1 3 /�nC1,r�/6 LA�PN —140— PARCEL SIZE �''/7 LAND USE APPLICATION# A OWNERNAME EIV M'10 JXJ •� I QL Srn: I J G/1,� .1 / �.t PHONE ��/y/�j y^'- j OWNER ADDRESS L7/W'f/l� A) �A5h0g1 �tJAJ�P CITY/STATE/ZIP: �,y�-l%//�-e/ / CONTRACTOR ad A//yy,,��,, PHONE �-`� / 3(07- S`fa 1 CONTRACTOR ADDRESS gn INQ/ST12-1/41- WAVI CITY/STATE/ZIP LA,I/ILII OWZVO SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS - CITY/STATE/ZIP ry� LICENSE Ilk-57 ❑C-61 ❑D-09 ❑Other NUMBER (*6o o y EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ INTENDED USE O Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring - Soil Sampling/Characterization Jill ❑Public Water System If different from Owner: Water Systam N cemect Nsme or Poo.N..ftl TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells 0 Soil Boring(,)�2 sof borings ❑Geotechnical Nofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Plump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method O Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth�1Q_ft Excavation in diameter 13Open Bottom E3Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft W Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel [3 Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) O Sand Cement sack mix/7 gal water D O Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File O Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Cl Driller ❑Pump Contractor ❑Other ` ❑Concrete Pedestal Dimensions: Width_ ft Length ft Thick in ❑Christy Box O Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 1b bag/5-10gal water) ❑Sand Cement sack mix/7 gal water Bentonite Pellets If I+«" ❑Bentonite(200/o solids) ❑Manufacturer Spec%solids % Name [3 Spas on File ❑Specs Submitted (h Placement Method 13Pumped [3Free Fall $Other -001L, 4&1TIA 7 ❑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 NVp 4409CCOUWW TITLE SrA9GF &J60N C&P— DATE 7/274 nFL CL Lie" b > ¢/ I �� ,.. �•.�!�� _. I e I �rT_1_---_ s ! lP4r 91 I, I9 lI T5 q19 f'Ig I9 Ir` .'. fv DEPARTMEUS T ON Y Application Accepted By DateNTQ ; D Area 2.11 Employee IDA Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date 13 WAIVER Received D�Ge r+tE9cn Inspection By Date Ion Constructed Well Depth It COMMENTS PE SC Received Check#/ Amount Date Permit/ Involve# Well tlHf Codes Info B Remitted Service Re oast# tf3. 1 ISD (oS'� 23 D. )) Dy `-7& MASTER WATER WELL PERMIT