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J�.HNNtU l0'v'0 WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTOPWARTMENT 304E WEBER-.,;%E 3'"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOBADDRESS 2'L7-61 5 Ma7roThIA) N-ul736 Pk.lA1l/ CITY/ZIP C-6 '75391 ��a �.-�_/� p� a CROSS STREET �� r�66 AP_N,t - 1's/s—OD PARCEL SIZE 1 4 LAND USE APPLICATION# F OWNER NAME D04=- 4 LI1_.Iert-) /�f lnn Rf ✓♦At77'lJ PHONE SL�i OWNERADDRESS 249 1 b S, 1`9 A%St ah K( -•> CITY/STATE/ZIP M4}rJTEY/� I GF} X533 6 CONTRACTOR1A��LJ� -F-IGVI11g. �iOL- G,P.HONE CONTRACTOR ADDRESS 3f'{IV IAI AANA1\4' - L ASE CITY/STATE/ZIP 52?zkC-TC /wL> J-1 IY.& Iii 9S�il�I SUBCONTRACTOR Y i W PHONE 'pyo / SUBCONTRACTOR ADDRESS /0z;7F/>=rr/ STB-L'�Y CITVISSTTATE/`Z,IP 1.9E7-Z1-,;LJ t t+ !SIJ7r/ LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 2T / 0_IW EXPIRATION DATE y GEOGRAPHICALINFORMATION: Coordinates X Y Township Range_ Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial 17 Water Quality Monitoring Soil SamplinglCharzeterization \ ❑Public Water System If ddlerenl from Owner: water system Name Con=t Naroo or Phone Nornber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring #ofborings %'Gs) rweotechnical Mofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION 0 Drilling Method ❑Mud Rotary ❑Air Rotary Auger Cl Cable Tool ❑Push Point ❑Other Proposed Well Depth W R 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 Sed Depth ZO ft )(Neat Cement(94 lb bag/5-10 gal water) O Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) 0103Rfll3elurer Spec a/solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall Other 7Yt/Mt E ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor O Other ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94/b bag/3-10 gal wafer) O Sand Cement sack mix/7 gal water ❑Bentonite Pellets 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS INSPECTIONS SIGNED TITLE 5(/'T�r t A)(7 k2. DATE ROAD UNE GRANT 'vgrW P Oon I a 07 ii irwrssO . I 4 !d Yy 1 e ise Cr ♦ r or z1 zl zz N E oe I c DEPARTMENT USE ONLY N Application Accepted By Date L 7"'�S' -- Area ,lf Employee IHR'-f4 yy Grout inspection By Date m—i -2ze3 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Checlu0j ) I Amount Date Permit/ Invoice# Well ID# Codes I Info Bv Remitted Service Re--t# SD — IA o 3oD EHD 4].02-001 MASTER WATER WELL PERMIT I V2n003