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WELL / YU1V1Y YEI K1V111 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH' -PARTMENT 304 E WEBF^s VE 3"FL-STOCKTON CA 95202 - (209)466-3420 .a NON-REFUNDABLE PERMIT '\/CALL 209 953-7697 FOR INSPECTIONS \.O,'XPIRES 1 YEAR FROM DATE ISSUED I T / ] JOBADDRESS l �I `M-' .A� v CITYIZIIPj -� M D CROSS STREET I'` I`��"� APN �/`!� I HJ G-^] �}PARCPEL S12E S� Gy.!. OWNERNAME /r1�r S/ OWNER ADDRESS Lle CITY/STATEIZIP CONTRACTOR t4 PHONE 2-5*CONTRACTOR ADDRESS I//V ✓_X/ I I�s/ CITY/STATE/ZIP ^) SUBCONTRACTOR PITON SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE L-57 ❑C-61 ❑D-09 ❑Other NUMBER3773?s E%PIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE mestic/Private ❑Irrigation/Agrlcultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System I fdifferem from Owner. .ter System Name ..tact No.or PFoo, um r TYPE OF WORK C New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells ❑Soil Boring(s) wmberofbodngs 13Geotechnical numbcrofboringe O Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal (� ICT4ew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair 3 WELL CONSTRUCTION Drilling Method�Mud Rota ❑Air Rotary O Auger ❑Cable Tool 13 Push Point ❑Other Proposed Well Depth r 0 R Excavation /—L- in diameter ❑Open Bottom -'420Qravei Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 in ThickneWGauge/ASTM Sched ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth 2� fl ❑Neat Cement(94 1b hug/5-10 got water) i;Mand Cement .tuck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted > Grout Placement Method srJJumped ❑FreeFall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pumdthp ntractor ❑Other ❑Concrete Pedestal Dimensions: Wi11 Length_R Thick in ❑Christy Box ❑Stove Pipe PUMP ,,7E%$ubnneruble 13Turbine 13 Other HP Pump Set R Standing Water Level tt WELL DESTRUCTION ❑Open Bottom O Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water tl ❑Casing to be Perforated from R to ft Sealing Material ❑Neat Cement(941#lag/5-10gu1 water) -❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(200/9 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap fi below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN UM 24 HOUR ADVANCE NOTICyE�REQUIRED FOR INSPECTIONS SIGNED �A— TITLE C/ /yy/ ". DATE AN 4 N DEPARTMENT USf ONLY _ _ Application Accepted By F—�0 Date p Z` �� Area Employee IDN �L Grout Inspection By Date (7- 30'e"7,- ❑ SPECIAL Well Permit Pump Inspection By G Date ❑ WAIVER Received Destruction Inppspection By Date p Constructed Well Depth It COMMENTS Q^SO.OZ alnA�/ .trjesa'I cws ds /SikSY$HrIJiP PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted By Service Request# o •vz Is-& Aol2te W30YL8Ddayaag 6 �Z1 otooa-1az,o EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002