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WELL / PUMP PERMIT �t7s-en &rr- � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH)NWARTMENT 304E WEBER!rh 3M0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLEPERMIT P CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ljnlLeww J2eggool Ae*0'' (AlWe) CIITTV/ZIP �rr 4S .z a CROSS STREET �(n[C��4�t tem� AP/N ✓//� "f -'D3()PARCEL SIZE`r' 27 LAND USE APPLICATION# �} s GFrC s-s/ yA1(1Ni 4 /fes(//" 4U^CS PHONE�Q/ - /Sl- IU12f OWNER NAME / Cf�l� r'�� / 1� /J OWNER ADDRESS ///7/ �i /�B✓ -fiC✓Y;woa1D /�e V CITY/STATE/ZIP�/, CONTRACTOR Xlerh/tp�/1C1�w Tye- (/ 1' / PHONE Z09-95�P CONTRACTOR ADDRESS B?&) S- L /�VY Ile S/J eOm7 CITY/STATE/ZIP� Cr� 9 fZd,g- SUBCONTRACTOR Sir PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 ❑C-61 0 D-09 0 Other NUMBER ��sa EXPIRATION DATE 3/ GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ INTENDED USE ❑Domestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring OSoil Sampling/Characterization ❑Public Water System If different from Owner: Water Symern No. Contact Name or Phone Number TYPE OF WORK 0 New Well ❑Replacement Well 0 Well Alteration/Modification ❑Test Hole 0 Other O Monitoring Well(s) #of wells ❑Soil Boring(s) xofbonngs )BGmtechnical 5: Illness 0 Well Destruction ❑Out-Of-Service Well 0 Out-0f-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair 0 Cross-Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑Air Rotary %Auger ❑Cable Tool 17 Push Point 0 Other Proposed Well Depth �-e20 ft Excavation & in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑Stainless Steel ❑Other .� Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name a4e4//M if(jG(/ }3 Specs on File ❑Specs Submitted Grout Placement Method 0 Pumped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) 1 PEDESTAL Installed By ❑Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP ❑Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft o WELL DESTRUCTION ❑Open Bottom 0 Gravel Pack 0 Untried 0 Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft nl Sealing Material 0 Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets 0 Bentonite(20%solids) 0 Manufacturer Spec%solids—% Name ❑Specs on File ❑Specs Submitted I^ Placement Method ❑Pumped 0 Free Fall ❑Other s' ] ❑Complete with Mushroom Cap ft below grade 0 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 JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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. Z MIM4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED �' TITLE DATE (O 2 V Pill V TA 1 t T .r _DEPARTMENT USE X _ Application Accepted By Date Area Employee ID# w " " Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Dasuneetmt Inspection By Date �� - Constructed Well Depth R COMMENTS PE SC Received Chec Amounl Permit/ Codes Info B Cash Remitted Date Service R ues[# Invoice# Well ID# �3� Iso ra�s8' z3o.� 0 2 83� EHD 43-02406 MASTER WATER WELL PERMIT 12,1]/20¢3