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WELL /PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH C TMENT 304 E WEBER 1"a FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT "VALL 209 953-7697 FOR INSPECTIONS r%PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS (�� ! JG>✓/1.� ,�(-✓l��i CITY/ZIP "'I X9141 / ��/ CROSS STREET APN �6PARCEL SIZE " r✓ z OWNER NAME / .•'r/ '✓' ��1 �„��`�� a�o4°o5 PIIONE' (ry/ OWNER ADDRESS //FF ��(J �y�6It `T / CITY/STATE/ZIP ��G-mac/1, �� / '"'T l�✓J� �7 CONTRACTOR /!�[/ /✓� �C V PHONE /� CONTRACTOR ADDRESS /'L� `7 / CITY/STATE/ZIP � �-fJ'LlG- 'l;1-P• %✓�? CJ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STAT E/ZIP LICENSE .0-'C-57 ❑C-61 ❑D-09 1:1 Other NUMBERS p EXPIRATION DATE `Z GEOGRAPHICAL INFORMATION: Coordinates X Y Township ?vim Range 7 �- Section or INTENDED USE ��estic/Private ❑Irrigation/Agricultural I ustrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization !B'Public Water Sstem S �t/I V� WPB>� a`49� If different from Owner: mer System Name Contact Name or Phone Number er TYPE OF WORK ,Lew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical '— ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION� Drilling Method ®Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Cl Push Point ❑Other / rn Proposed Well Depth ,300 ft Excavation 14F in diameter ❑Open Bottom ravel Pack/Gravel Size ?X/rC in diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl �- Well Casing Diameter 1fi in Thickness/Gauge/ASTM Sched V , /7 ❑Steel lastic ❑Stainless Steel ❑Other Grout Seal Depth ,7� ft ❑Neat Cement(94 lb bug/S-/0 gal water) 0!and Cement/ suck mix/7 gal water ❑Bentonite (20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method 9? umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ump Contractor ❑Other Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ti 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(94 lb hag/5-10 gal water) ❑Sand Cement .ruck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IMUM 24-HOUR ADVANCE NOTICE QUI D FII? INSPE,C/JT'IIONS SIGNED TITLE, ��GYWL DATE PAY 9 - K N JUP S EN DEPARTMENT USE ONLY Application Accepte Date �� ' G'y •,0 2-- Area "1 Employee ID# >a�� Grout Inspect, Date l?i '6-5 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Deptl ft COMMENTS Eitgl 661-a7.-4-be ZV-,4CJS COv--04 t'dh el -;rY-3 - �i�' /0/07 6-�1 r ri ✓w-�- PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Service Request# 5b 35r7& EHD 43-02-006 MASTER WADER WELL PERMIT 5/7/2002