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# 4570 WELL It PERMIT eL.;-� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 law NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED a JOB ADDRESS 550 N. Hewitt Road CITY/ZIP Linden 95236 am CROSSSTREET Fine Road APN 093-030-63 PARCEL SIZE OWNERINAME Ray Butler PHONE 887-3536 ` ar OWNER ADDRESS Same CITY/STATE/ZIP CONTRACTOR Delta Stockton Pump PHONE 466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATFJZIP LICENSE ❑C-57 0 C-61 ❑D-09 ❑Other NUMBER 724778 ExPHIATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE :UDUMCalic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charaelerivation ❑Public Wafer System If dirterem from Owrcr. Wow gym. ame Domer ons or Phone Nuenber TYPE OF WORK Cl New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells 0Soil Boring(s) numberofborings ❑Geotechnical numberofborings ❑Well Dwruction ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal O New Pump 20 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair ` WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑Push Point ❑Other Proposed Well Depth H Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Casing Diameter _in Thickness/Gauge(ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth H ❑Neat Cement(94 1h bug/5-10 got water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs of Fite ❑Specs Submined .. Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) n PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑.A�Concrete Pedestal Dimensions: Width_ ftLength_H Thick in ❑Christy Box ❑Stove Pipe Pump aSubmerslble ❑Turbine ❑Other HP 10 Pump Set 189 R Standing Water Levet 137 ti WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack Cl Uncased ❑Other Well Diameter_in Total Depth it Depth to Water ft ❑Casing to be Perforated from R to R Sealing Material ❑Neat Cement(941b bag/5-/0 got water) ❑Sand Cement sack mix/7 gal wafer ❑Bentonite Pellets f ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted C Placement Method ❑Pumped ❑Free Fall O Other ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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. °i INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE 06/17/04 Ir CPO r tit J r to - Et DEPARTMENT USEPN LY N ad Application Accepted By Date 2 t Area `.Z it Employee IDR J54L/ /'I C( - Grout Inspection By Date ❑ SPECIAL Well Permit -- Pump Inspection By Date � —7s ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COMMENTS PE SC Amount thee Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Request# 3-91 oSu so, 611 If 0 D Qcc 3$51 EHD 43-02.006 MASTER WAl'ER WELL PERMIT 5nn-om