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x/2657 WELL / YUNIF FV WV111 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT' 'SPARTMENT 304 E WEP' 4vE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT r CALL 209 953-7697 FOR INSPECTIONS .,/EXPIRES 1 YEAR FROM DATE ISSUED 1 JOB ADDRESS 3409 Pock Lane CITY/ZIP Stockton 95205 CROSS STREET APN_ ! T1 PARCEL SIZE z m N OWNER NAME 1X$2 Kiril Dimitrov PHONE 466-1954 ti OWNER ADDRESS Same CITY/STATE/ZIP CONTRACTOR Delta Stockton Pump PHONE 466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIPStockton, CA 95203 SUBCONTRACTOR PHONE r V SUBCONTRACTOR ADDRESS C rrY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE N Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) 11 Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump X7 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth tt ❑Neat Cement(94 lb hub/5-10 bat water) ❑Sand Cement suck miv/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed BY ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ti Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 0 Submersible ❑Turbine ❑Other HP_11�_ Pump Set 136 ft Standing Water Level 65 ft 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 1b bub/5-10 ba/wider) ❑Sand Cement suck mia/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 I 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. I 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED �i 2 2.. -� TITLE CEO D,%TE 12/10/02 I SAN JOAQUIN CO 7 DEPARTMENT USEONLY � ApplicatlOBL*V49 R �— — Date 2 p' y- Area d� Employee ID# ENVIRON+MR4 I MFA T" GGrout Inspection B Date ❑ SPECIAL Well Permit Pump InspectiBy - Date -L//oZ ElWAIVER Received Destruction It§ ection By Date Constructed Well Depth it COMMENTS /%`� c` s PE SC Amount / Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By I Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002