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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY EN%'IRONM PARTMENT 600 FAIT NlA1N STREET-STOCKTON CA 96202-(209)46$-3420 <br /> t NON-REFUNDABLE PPnER a 9oD 1•/?,'L/� EXPIRES 1 YEAR FROM DATE ISSUED <br /> t JOB ADDRf.&S cttY(ZIP /�/AEN��'�9S1j "• <br /> ��JJ' <br /> CROSS STREET S CK— Di¢- - --, ,�6/_—��—PARCEL Sim:_ -. <br /> OWNER NAME —`'II/I <br /> 901 0 <br /> OWNER ADDREM _ z V oI_�^ CJTY/StATlVTJP �_ <br /> CONTRACTOR 7 w ✓�+ I �'I PitONE �— �J`a• I-?, <br /> CoNtrR <br /> 'IRACTORADE% /D`O dZ6 CITY/3TATErAP <br /> SkincoNTRACTOR PRONE <br /> SUBCON7 RACI'OR ADMMSS -- CrIriSTwTrILP <br /> LicEls's: a C-57 C-(+1 ❑D4)9 O Other NhIBN6R EXPIRATION DAIM <br /> GEoGRAPtuCALINFoRsfA*itoN: Coordinates X- Y Tewaship— R=V Section_ <br /> INTENDED USE ❑Domestic/Privatc IrrigationlAaricuhlRal 0hN1111511M O Water Quality Monitoring OSpa SautpussAcharn,lcriruion <br /> ❑Public Watcr System — — —_ ___.____._ _.._ <br /> IfdiRernor fins tkvner: w—Sysnu Naas (:o X—atpbae Wn6a <br /> TYPE OF WORK O New Well O Replacement Well O Well AlkittlionfMcdification O Tat Hole O <br /> O Monitoring Wells) uumhrMwcus p Sal Borings) uunndxrofboriq& O Gcotecimical <br /> O Well L-An ciion O Om-0f-Service Well ❑Out-0f-Srnice Well Renewal <br /> New Pump 0 Pump Rclplacemcm O Pump Repair O Cross-Connection Repair <br /> WELL CONSTRU TI N <br /> Drilling Method O Mod Rotary O Air Rotary O Auger O Cable Tool C Push Point O Othcr__ _ __-_._ <br /> Proposed Well Depth___ __R Excavation in diameter O Olsen Bottom ❑Gravel Pack/Gravel Sim--in diameter <br /> OCemductorCasing_ indiameter / Conductor Casing Depth0 <br /> Well Casing Diameter__in ThicknowGiruge'ASTM Schcd _.- ❑Steel O Plastic O Stainless Steel O Other _ <br /> Greet Seal Depth 0 O Neat Cement(941b bag/5-/0 gat uwe) O Sand Comm a wk arty/7 gal water <br /> 0 Bentonite(20%solids) O Manafacturcr Spec%Aids—_% Name _ O Specsoa File O Spect Sobteitted <br /> Groot Placement Method O Pmnped O FMC Fab O Other O Retardant/Accelerator(than) <br /> PEDESTAL Installer!BY O Driller O Pump Contractor OOW¢r— --_-_-.----- _- ------- <br /> ❑ConcretePedestal Dimensions: Width_R Length_—•R Thiele_ in ❑ChrWyBn O <br /> POMP ,uhrnemblc Turbine OOlherHP Pump Set.__..._Xl Standing WaRrLcvd B <br /> WELL DESTRUCtr r, ❑Open Ilonorn O Gravel Pack O Uncased O Other_ <br /> Well Diameter__._ __,in Total Depth__.ft Depth to Water 0 O Casing to be Perforated from R to B <br /> Scaling Material 0 Neat Cement(941b bag/5-70ga/enter) O Sam Cement _,_sack Prix/7 gal water O Beatonite Pullers <br /> 0 Bentonite(20%solids) O Manufacturer Spec%solids._4o Nerae O Specs on Fitc O Specs Su mtitted <br /> Placement Metered 0Punped 0Free Fail OOther.___­­_ <br /> ❑Complete with Mushroom Cap ft below grade O Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITi' CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I Alf IN COMPLLINCE WITH ALL <br /> WORKERS COI\ I i <br /> S3GN TITLE V w/V DATE <br /> r7--1- <br /> WENT <br /> LVED <br /> 8 2019 <br /> MAN N <br /> N COUNTY <br /> =A1 Tt ENTAL <br /> TMENT <br /> DEPARTMENT <br /> Application Accepted B Date Area a -f - I Etvpltyyce IDp <br /> Grout Inspection By DateSPECIAL Well Permit <br /> Pump,Inspection By Date--N tY I..J ZOfl 0 WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth__ .R <br /> COMMENTS <br /> PE SC check#/ Amount Permit/ invoice# WdlID# <br /> lafo Cask f. R t# <br /> 9 12, <br /> EHD 43-02-006 WEB Well Pernnr and Ueclarafim.doc <br /> 9/11/2007 <br /> d ; <br />