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L SANJOAQUINCOUNT ENVIRONMENTALHEALTII DEPARTMENT v y V_304E WEBER AVE 3"'VL-STOCKTON CA 95202 -(209)460.3420 NON-P.EPUNDABLE PERMIT CALL 109 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED / Y JOBADDAEES /'1'wl� ✓✓ �7T //G✓�J'� • /1W�✓��- CIT1'/ZIP J/" ��yv CROSS STREET 1 (✓'r " APN L�k�t`I I IJ L' «d UPn�}pc�EIL SIZE/ 1 a DSVNfR NAME �/'MI �/Q�Q(�. PIIONE I /L'/ /-�� OWNER ADDRESS L CMtISTATE/ZIP CONTRATOR C/ ' 91g; e J/�! 1PHONE CONrnwROR ADDRESS 13c ///-I% 1 a 1 CITVISTATEZ.1 SUBCONTRACTOR PIIONE h SUBCONTRACTOR ADDRESS CIT'/STATTEMIP LICENSE ED C-57 0C-61 0D-0 Algther 0 -Z NUMBER E%PiRATKiND.\TE GEOOMPHICALINFORMATION: CBDrdlnares X Y Township_ Range_ Section_ r IHFENDEDUSE IiGPdvalc T 01DigalioNAgriculwml ❑Industrial ❑Water QueliQualityMonitori ng Na—s ❑ oil^SmGpling/Chennerimtion T 0 Public Water System 0di0ma finun Ower: c roent TYPE OF WORK 13 NM Well 011'acemem Well O Wall AIlalttlil/Modifcalien ❑Test HNB 13 Other ; O Monitoring Wallis) o^ urwas O Soil Bming(s) a"'t'Bn.rco—, O Geotechnical ^aa*-.fIMrmrn O Well Destruction OOut-Of-Scrvice Well OOutAf-Service Well Renewal ❑New Pum R lsocmem 0 Pum Rc i 0 Cmss-CcholOmn Rc air We,t CONSTRUCTION Drilling Method 0ed Mud Roary ❑Air Be,.,R 0 Auger ❑Cable Tool 0 Push Point 0 Other L ProposWell Depth E uwnion diameter 0 Open Bottom 0 Gravel Pack/Gravel Sirte Siren in diamer �P ❑Conductor Casing in diameter / Conductor Casing Depth It !C Well Coastal Domutcr_in ThicWess/Gaaga/ASTMSchcd OSteel OPI.tia 13Suiniess Steel 13 Other Grow Seal Depth R 0 Nast Cement(p4/A Aug/5-10 gal w far) 0 Send Cement .mck mu 17 1 water 0 Benterrum(2O%solids) OManuRcww Spec Yesolids_% Name ❑Specs..File ❑Spec Subnsieed Grou'Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(nam e) PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑Other C 0 Concrete Pedosml Dimensions: Width_ It Length B Thick to 0 Ch,art But 0 Steve Pipe 1_ POMP �E3Submemble 12 Turbine 00ther HP / Pump SetR Standing Water Level r 11 WELLDETI'RUC-TtON ❑Open Bottom ❑Gravel Pack 0 encased 001her Well Diamner n Total Depth R Depth to Water 11 0 Casing m be Perfnal d frum R ID it Sealing Material ❑Neal Cement(94/It ba,,1540gul woler) ❑Sand Cement suck mu'/]gal water O Bentonite Pellets 0 B.mmu,(20%.solids) ❑ManuBcturer Sptt Y solids Y Name 0 Specs on File 0 Specs SUbmipcd Placemen'Method 0 Pumped ❑Free Fail 0 Other P ❑Compiem with Mushroom Cap h below&rude 0 Complete ID 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS LCURRENT ANDACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL [4` WORKERS MP IS 7 S. , f l%,} MINIMUM 24 HOUR ADVANCE NOTI�C'j�REIRED FOR INSPECTIONS `` V �� S16NED C{I Tr''LE -CG DATE 14f asIII `r 5 N 1 EI ��yn e/,'rL /' --�� ,,pJL PARTMENT USE ONLY Application Accepted By Zt1.''l'Lw-t lir - 1,A-Gl 1 Data 1�1�5 -s A. 11 Employee IDN Grote Inspection By Dela ��/''' ��/��-''' ❑ SPECIAL Well Permit Pump Inspection By Dole ❑ WAIvER Received De9ruetiOn Inspection By Date Constructed Well Depth It COMMENTS PE SC AmoaChe Received Dale Pem1nV Utvoi<eq "'Pit JON Codes Info Remittee sit ash By Scrvice Re tint❑ jD R13 �D rr'' ,'' li'7 gal 1 END 4M2-M6 MASTER W A'El N W tffMI I� 50000212 1 fo