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44782 WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 1._ ARTMENT 304 E WEBE("")E 3"°FL-STOCKTON CA 95202 - (209)46$-3420 NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA JOB ADDRESS 15494 Cottage Avenue CITY/iIP Yahteca 95336 y 1 CROSS STREET Lathrop APN 208-030-08 PARCELSIZE0,35L LAND USE APPLICATION# OWNERNAME Warren & M ril Kooken C3 into MP U3-3868 i LUPY OWNER ADDRESS same C1 TEI 't '. CONTRACTOR Universal Putn PHONE 466-9625 ' CONTRACTOR ADDRESS 646 S. California Street CITYISTATEIZIP Stockton, CA _95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE ❑C-57 )ffC-61 ❑D-090 Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION:' Coordinates X Y 265761 Township Range Section INTENDED USE I1 Domestic/Private ❑irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization i ❑Public Water System • If different from Owner: Water System Name, Covtaci Name or Phone Numr I TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole- ❑Other ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) ftofborings ❑Geotechnical Nofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump XXPump Replacement ❑Pump Repair ❑Cross-Connection Re air 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 1 Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids °/a Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall "❑Other ❑Retardant/Accelerator(name) t PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other �, 1 ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Pump 10 Submersible ❑Turbine ❑Other HP l Pump&t : 63 ft Standing Water level 24 ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑"Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to beTerforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 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. 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. . ° .7111" . 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE 07/28194 Q IN Vi O LT IL IL v - DEPARTMENT US ON Y _ _ A.pplicahon Accepted By` - Irate - Area Employ-ee:'1D{f"- J Groot inspection By __II Date. ❑ SPECIAL Well Permit Pump Inspection By JA-Cr a aDate 12-2(}-QLL ❑ WAIVER Received Destruction Inspection By Date Constructed Weli'Depth ft COMMENTS PE SC Received Check#/ Amount ` Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Re uest# Z,6- 1131 sa,rl�) o sJO EHD43-02-006+ - MASTER WATER WELL PERMIT 12/2212003