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f� WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH fEPARTMENT 304 E WEBE1111111l 3°"FL-STOCKTON CA 95202 - (209)468.3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED H f3 , ;I JOBADDRESS "CCirf'I d��--F.`�— � 4 _ CITY/ZIP f�Z"I` N Y .I r1 t O h'J�Af S'>-• APN 15ol 0� 4'11r PARCELSIZE Il' rt LA U1F11AP CAT CROSS STREET /\ Vl `-'l.. PHONE OWNER NAME /� OWNERADDRESS �✓ / YJ fV L ¢• y� CITY/STATE/ZIP NEIL o �/✓d Chr �/i iYJSc! PHONE o4-34-7-)`101 CONTRACTOR eye _ CONTRACTOR ADDRESS 07 IMrJ 115"M'1/5L- 'U"'A-tib-- CITY/STATE/ZIP �r/ri1°' ZYiO PHONE IWO SUBCONTRACTOR SUBCONTRACTOR ADDRESS CITY//STATEIZIP LICENSE C-57 0C-61 0D-09 ❑Other NUMBER 411d9oo`I EXPIRATION DATE Voillill GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characlenzation O Public WaterSystem ontact eme or one um r Ifdifferenrfmm Owner: ater ystem ame TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other a of burin (, ❑Monitoring Wells) #o(wells r�Soil Borings) 8 a of borings ❑Geotechnical gs IVr ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair r('� WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary U�Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /t) ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Z Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other 7 Grout Seal Depth ft ❑Neat Cement(94 Ill bag/5-10 gal wafer) O Sand Cement .rack mix/7 gal Water , ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids_% Name O Specs 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_ ft Length_R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible O Turbine ❑Other HP Pump Set it Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Unused ❑Other Well Diameter_in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to It Sealing Material ❑Neat Cement(94 lb bag/S-10 gal water) ❑Sand Cement sack mix/7 gal water W Bentonite Pellets IF 13 Bentonite(20%solids) ❑Manufacturer Spec%Solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 13 Free Fall 16 Other Iotsi- etYIT.010 ❑Complete with Mushroom Cap ft 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. MINIMUM 24 HOUR ADVANCE NOTICEREQUIREDFOR INSPECTIONS SIGNED �rTrF r` 0�-� T7`4'rr�Yo DATE H t[aGirR M. IL ® � 3 O4 tW B ^--'�K- 2/ Date /a/ Area. ,2:::// Emolovee 1# till; f Grout Inspection By Dale ❑ SPECIAL Well Permit 011 j Pump Inspection By Date ❑ WAIVER Received Inspection Date Constructed Well Depth ft COMMENTS PE SC Received heck#/ Amount Date Permit? Invoice# Well ID# Codes Info By Remitted Service Request It yill /6 3 23d to p EHD 43-02.106 MASTER WATER WELL PERMIT 12!22/1003