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WELL / YU1V1Y FERIV111' SAN JOAQUIN COUNTY ENVIRONMENTAL_HEALT,"* PARTMENT 304 E WEgfi IVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT - CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED .333 /'YI ouse JOB ADDRESS - CITY/ZIP, rAzq— m CROSS STREET N� APN ;2 9—`�� `�30 PARCEL SIZE L OWNER NAME r, fJ�� +liGP/r��V __ PHONE OWNER ADDRESS CITYISTATE/Z1P 11 qt` W CONTRACTOR P}ION F curl CONTRACTOR ADDRESS CITYISTATEIZIP l� SUBCONTRACTOR �1c1��el�t_r _ PlIONE 1Z��I 1– `n–ApS–VN.SJ� SUBCONTRACTOR ADDRESS 2� S V I1 L� CITYISTATEIZIP�93�1 LA 0e\ q 1520:i I f � I LICENSE C-57 C7 C-61 11D-09 ❑Other NUMBER � SZ EXPIRATION DATE t� O GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range _ Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water System If different from Owner, Water System Name Contact Name or Phone Number TYPE OF WORK a New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of borings number of boringy` ❑Monitoring Well(s) number of wells ❑Soil Boring(s) XGeotechnica] s�L ? ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair 0 Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary [Auger ❑Cable Toa] ❑Push Point ❑Other Proposed Well Depth ±/6 tl Excavation f4-6 in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diamete ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth tt ❑Neat Cement(94 th hub 15-10 gut water) ❑Sand Cement suck inix 17 gal water ❑Bentonite(209/9 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Meihod ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tl Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hag/5-10 gal water) ❑Sand Cement sack inix 17 gal water K Bentonite Pellets 7'f Gib.. , s ctY1GOUKl`c ❑Bentonite(200/.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other Complete with Mushroom Cap tl below grade ❑Complete to 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. I 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. IN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE OO DATE 1 A - ;�tFi'aw,j; \ •x;39 '' •'II 4�. ^, .. iiV G 0 / C`x r ER CE DEPARTMENT USE ONLY Application Acccpted By Date f� ~�� Areae" EmpIoyre 1D# Grout Inspection By_ Date El SPECIAL Well Permit Pump Inspection By Date D WAIVER Received Destruction Inspection Date ��l�Z Constructed Well Depth ft COMMENTS /q3$2 GlL4�T7T�O. F PE SC Amounthec 1 Received Date Permit! Invoice# Well IR# ' Codes Info Remitted ash B ae Service Re uest# EHD43-02-006 MASTER WATER WELL PERMIT sn1 m