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` ,,� WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBI NPNIt I'E 3aO FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM/jDATEIIprSSUED Lo JOB ADDRESS Z2 ZtOI S - �'�r�!-(rte] -(/J {-t f/L(S"E y�(Cet) }/CITY/ZIP I�AC- vl _�/J � � r''r� p / O CROSS STREET C—r�rCN r L e ti E APN -C/tel'"J q Vim- tj PARCEEL SIZE I y �TCLAND USE APPLICATION# OWNER NAME M C-1440V 'L-li( '{ I(.(�I t �P� /�P�H�ONN�Ef / /j /� ' OWNER ADDRESS a q(ra S M�1/ f CITYISTATE/ZIP ( FJ'yj��^/ 2-42- '3q CONTRACTOR 1M Gi I�C,(C- —1 L1,1-1 11 I -e FTS//S�i'11 e'��5 (�PHONES�(7 -2 ()t,l{�� f 7 2-4-. CONTRACTOR ADDRESS 7 �1to V� ��- 4w Lrti �1�`t If CITY/STATE/ZIP SUBCONTRACTOR //.� PHONEI} 2l' 7 (l�?L- L /00 L SUBCONTRACTOR ADDRESS Y� U 37l_:X I b CITY/STATE/ZIP I� 1A,� C(�- LICENSE C-57 ❑C-61 0 D-09 13Other NUMBER 72 0'-k' EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ INTENDED USe ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characteriration ❑Public Water System If,ifferent from Owrier water ystem ame Conuot Nrone,or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells Soil Boring(&) Z s of b0riop ❑Geotechnical #of borings ❑Well Destruction ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair O Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary "Auger ❑Cable Tool ❑Push Point ❑Other -1 Proposed Well Depth Al/I iiM ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter 1V ❑Conductor Casing in diameter / Conductor Casing Depth It N N Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel 13 Plastic E3 Stainless Steel ❑Other � Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water O Bentonite(20%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 nJ ❑Concrete Pedestal Dimensions: Width ft Length it Thick in ❑Christy Box ❑Stove Pipe Pump 0 Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Tonal Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft )` Sealing Material Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted "F 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 h JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS m 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 Tf SIGNED A,Y\-c.,7 7�j f� lL'E� TITLE � Qcl�o�tl`�J DATE i —SEC. 16 a. qd /+ T. 2 S. R -® ® t..�®Lvr�r'LJ I SCALE la 4� "N89EaBpAIN Y^ �r •-!Y ,NJ a 9 Yaps w% /-Ar. wId2�IaM�� J l I, Q �_M MCKa u' 4rv3 If la XA - �JMV i`_'I_ a a ° 1JUN 15 �C1D4 ENVIRONMENT HEAL' / DEPARTMENT USE ONLY Application Accepted By� f�D� DateQ&5/0—� Area_ -�CJ _, Empbyea IDN` �Sb J/L/.7•7•• r Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction inspection I�Ivyv((( ByR /e��!/GIA Date w Constructed Well Depth yy��/ COME T (/ 01 Z r - A/' e i PE SC Received -(CheckAmount Date Permit/ Invoice# Well IDN Codes into B ash Remitted �1',S.'ervice Re nest# Y9 7 23n /s le(J ILI EHD 41-02W ILI-q04` -r�(�^ - MASTER WATER WELL PERMIT iv2v2nm �- 9 t 9-o/r -