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1, WELL/PUMP PFS"IIT SAN JOAQUIN Ck ..i(ENVIRONMENTAL J'IVAt.9'll DEPARTMENT jiO4 E W£BE:R AVE 3"n Pl.-STOCKTON CA 95202 -(209)468-3420 i! NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTION'S EXPIRES I YEAR FROM DATE ISSUED I ! `o n JOA ADDRESS PA v — CtT'YYLtP J1^4 i CROSSSTREET ()LI'N-( �APN Z Z PARCELSIZEI'-.4fes1,:_f LANoA"UrtS�F.�AtPY-LICA/TIUNl_ R)! 03- OWNER �dA NAME !Y l' \ �j (� PHONE OWNERADDRESS C7 �U CITY/STATE/"/,IP1)P1 VKX)4 Lf S CONTRACTOR PRONE Ey CONTRACTOR ADDRESS CHNISTATE/ZIP .I SURCONTRACTOR PHONE .v �i SUBCONTRACTOR ADDRESS CI'TYJSTATFJZIP LICENSE 0 C-57 ❑C-61 ❑D-09 ❑Other NumilER EXPIRATION DATE. jl CEUCRA I'll ICA 1,I NPORMATION: Coordinates X Y' "Township Range Seclion f INTENDED USE ❑DomL5liclPlcrrivSayteslcm ❑IrrigatiunAgriculmru ❑Industrial ❑Water Qual ity Monitoring ❑Soil Sampling/Chant cterVAI..n ❑Public Wa I!dinarrm 1-No-N r TYPF,OF WORK Q New Well ❑Replacemcin Well ❑Well Alrerwion/Modifieatiun ❑Test I lute ❑Other jj p of bnrin6s ❑Monitoring Well(s) #n1'wclls C]Soil i3nring(s) 9a(b.rings'_ ❑Gcotechnicul i �1 ❑Well Destruction ❑Out-01'-Service Well ❑(fat-01=Service Well Rencwal 11 0 New Pump ❑Pump Replacement ❑Pump Repair Cross-Cann Ilion Repair it WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger 6 Cable Tool ❑Push Point ❑Other :I Proposed Well Depth It ]excavation in diameter ❑Open Bodom 0 Grave!Pack I Gravel Size in diameter V ❑Conductor Casing in diameter I Conductor Casing Depth f1 kJ fl Stainless Steel ❑Other J Well Casing Diameter in ThickncsslGauge/ASTM Sched Steel 0 t Grout Seat Depth fi ❑Neat CC.11Cn1.(94 lb hal;/540 gul ware•,,) ❑Sand Cement aaCk miv 17 gal water j� ❑Bentonite(20%solids) ❑Manu FaCILLrer Spec%solids % Name ❑Spces an Pflc ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) i PEDESTAL Installed BY 13 Driller 13 Pump Contractor ❑Other • ❑Concrete Pedestal Dimensions: Width ft Length_R Thick in 0 Christy Bos ❑Stove Pipe J'� .. PUMP d SubmersibJe ©Turbine ❑Other HP Pump Sea R Standing Water Level It 0 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other i� Weil Diameter in Total Ikpth R Depth to Water R ❑Casing to be Perforated rrom R to R [) 1 Sealing Material ❑Neat Cemcul(94 th hug/S-lO gal unary ❑Sand Cemcnl _ -,-k rrrir 17 gal wulcr EJ Bentonite Pellets IF ' ❑Bentonite(20%solids) ❑Maauracturer Spec A,solids % Name 0 Specs on Filc El Specs Submitted' Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap n below grade ❑Complete to Existing Surface Pad # '1 1',IIERE1tV CERTIFY THAT I HAVE; PREPARED THIS APPLICATION AND'I'IIAT TIII? WORK WILL RE DONE IN ACCORDANCE W1111 SAN JOAQUIN COUNTY ORDINANCES, .STA'fl{ LAWS, AND RULES AND ItEGULATTONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS E, CURRENT ANACTIVE WITH TIIE CAI.IPORNIA CONTRAC'1011S s-l"A'IF LICENSF. HOARD AND T'IIAT I AM IN CT)MI'L1ANCt: WIT11 ALL I WORKERS COMPENSATION ION LAWS. €1 _� f411NIR4UM 24 IIt)UR ADVANCh:NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE _101.fl, DATE tie,, ES _ I I� r 13 - EI v L j � I {{ L I ;I h DEPARTMENT US ONLY moi Application Accepted By ?� .'c---- Date C ,-a_ _____ Employee IDW/7�,S Groat Inspection By Date ❑ SPECIAL WCII Pernsit ��• Puntp Inspcc Gun By Dctc__�_7//11i%- ❑ WAIVER Received f- Destruction Inspection By Date Constructed Well Depth It fi COMMENTS�/7 O 3 PE SC Received kf.ILOCW Amount Permit! atr ';Codes Info sh Remitted Service Re urs!# Invulce# Well ID# EHD43.02-OOM1 MASTER WATER WELL PERMIT 1 211 312 0 0 3