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y "I. WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER,,.,6'"FL-STOCKTON CA 95202 - (209)468-3420 N04-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED X JOB DDRESS L CITY/ZIP c-- Y CROSS STREET © APN QOJ U / PARCEL SIZE p s m OWNER NAME % PHO/ / NE OWNER ADDRESS I VLJ t P CITY/STATE/ZIP �`// ' / (/�� CONTRACTOR 112PFIONE N CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 C-61 11D-09 ❑Other NUMBER �T EXPIRATION DATE 7 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑Irrigation/Agricultural„Q ❑In�yyStrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Public Water System a0 h(4 /"dye If different from Owner —ester System Name Contact Name or Phone Number 1E TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other r1 ❑Monitoring Well(s) number of wells ❑Soil Boring(s) numberofborings ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal New Pum ❑Pum Replacement ❑Pum Repair ❑Cross-Connection Repair WELL CONSTRU ION Drilling Methods Mud Rotary ❑Air Rotary Q Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sche�H— ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth /bb ft ❑Neat Cement(94 lb hag/5-10 gal water)�(1 n Sand C ment sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name r Specs on File ❑Specs Submitted Grout Placement Method 011rumped ❑Free Fall ❑Other ❑Retardant/Accelerat (name) PEDESTAL Installed By A(Driller ❑Pump,C2ntractor ❑Other Concrete Pedestal Dimensions: Width-hk ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP Pump Settt Standing Water Level ��_ 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 lb hug/5-10 gal water) ❑Sand Cement sack 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 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. I 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. MI HOUDVANCE NOTICE REQUIRED FORINSPECTIONS—PLEASE CALL(209))953-7697 z SIGNED L�r - TITLE �/I LSI DATE /C/ O_l 11 4,r n i° s ' a, I C y, DEPARTMENT SE ONLY .fJ�. Yc --n-'per Area Employee iDti Application Accepted By Date Grout Inspection By��)� N6) Date I 0 ❑ SPECIAL Well Permit Pump Inspection By l/J, N� Date S'Z�j-0`� ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received kcLeSILOK Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Re uest# 5,2,5 '4350 S k7," 35 So a 5�5 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002