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WELL/PUMP PERMIT !T1f`h` A a�p��,//qj�� SANJOAQEIN COIUNTY EN%IROv1ENTAL HEALTH DEPARTMENT 304E WEBER AN'E3"FL-STOCKTOR CS'9426 2 �4Kg-3320 Vg NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 }'EAR FROM DATE ISS,ED JOe ADOBESN 16752 N. JACKTONE RD. CITI'/ZIP LODI, 95240 / G CROSSSrREET KETTLEMAN LN. APN PS3 —D.3�'�/,$� PARCELS= v2 c�.Ci to 60 OWNER NAME JULIE GUEVARA PHONE 368-1202 OWNER ADDRESS 16752 N. JACKTONE RD. CITY/STATE/zip LODI, CA. 95240 CONERAcrDR NOACK PHONE 948-8817 6. CONTRACTOR ADDRESS 4500 E. FREMONT ST. CITWSTATVZIP STOCKTON, CA. 95215 (V SURCONTRAETORI PHONE `;1 LSUBCON,—,,-RIAODRMS CITY/STATWZIP \J LICENSE YI CjS7 [1 C-61 [I D-09 DOther NUIlit EXPIRATION DATE GEOORAPRIGL IKPORMATION: Cri.ulrcelea X Y Townaglp Rvnge Seclian INTEnoEO Use It&Domorme/Privaw Cl Imgation/Agricultuml Cl Industrial O Water Quality M.mumng ❑Soil Sampling/Chametenution L ❑Pumrten armr.0 tMm y:rcm k. rin TYPE OF WORK D New Well ❑Replacement Well ❑Well Alwouton/Madification ❑Test Hole ❑Other ` ❑Monitoring Well(s) mmhn otwell, C]Sell Boring(s) n.annootbmmp ❑Geotechnical nureerorhmings C, ` j❑Well Destruction ❑Out-0f.Service Well ❑OutAl=Service Well Renewal "1 .❑New Pump ❑Pump Replacement jP Pump Repair ❑Cross-Carnation R it W ELL 13g MethRCL D Drilling Method Mud Rosary Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other UUU PuW,,d Well Depth fl Excavation in diameter ❑Open Bottom ❑Gncel Pack/Gra,el Size in diameter L Cl Conductor Casing in diameter / Conductor Casing Depth 0 Well Cuing Diameter_io Thickn,u Gauge/ASTM Sched ❑Steel D Plastic ❑Stainless Steel ❑Other Grout Seal Depth H ❑Neat Cement(94 fl,hog/810 gal wale.) ❑Sand Cement rack at<c i 7 gal water !❑Benm ute(20%Solids) ❑Manufacturer Spec°o solids % Name ❑Spas on File 17 Specs Submined Grout Plaeemem Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(mme) PEDESTAL Imtalled By ❑Driller ❑Pump Contractor ❑Other ❑Cancrtte Pedesral Dimensions: Width H Length H Thick ❑Christy Bax D Stove Pipe PUMP 00 Submersible D Turbine ❑Other HP 5 Pump Set 470 A Standing Water Level 124 A `mss WELL DESraUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other I Well Diameter in Total Depth fl Depth to Water a ❑Casing to be Pttf cared fmm fl tD 11 Selling Mucci l O Neat Cement(94 fh hag/3-f0,./water) ❑Sand Cement vack mtr/]gal water D Bentonite Pellets D Bmtonilo(206 solids) ❑Manufacturer Spcc%solids_% Name ❑Specs an File ❑Specs Submitted Placement Method ❑PumpM ❑Free Fall ❑Other D Complete with Mushroom Cap R below grade ❑Complete to E,ozmg Surface Ped 1 HEREBY CERTIFY THAT 1 HA\'E 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 L CURRENT AND:ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI;�IWM 20 NO - ADVANCE NqTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ..t TILE RETAIL SALES DATE 30 SEPT. 2003 L R DUL Ile are L 5 N OU pU IC t til'SWIION 7T lr� I I A �f/ DEPARTMENT USE ONLV Application AcCepIW By/Yiw4at.� ✓r Date %e'_:2 .Area .n/�2, EmPluyec IDe Grout In tion By Date ❑ SPECIAL Well Permit Pump Insp ion B, Date ❑ WAIY'ER Received ` Destruction Ivan.coon By _ Date Constructed Well Depth It COMMENTS -�tiD_�jc- _ _} C .wti - _ r`V r/- ".4 L- /> <`,1 q- v(_ PE SC Recelvetl hec I Amount Data PerrnW Invoice# ",It ID# Codes INb By s Remitted Service Rumeta L EHD 43-02--006 MASTER WATER WELL PERMIT 2/62002