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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D TE ISSUED H H JOB ADDRESS '7 �p t..r, CITY/ZIP -1F�O°""-r '/S // Y t ✓)r L-V! �W I PARCEL SIZE o CROSS STREET I fit' r� 1 LAND USE APPLICATION# OWNERNAME 1.E{rri�-yGl? ( �' Nftft -)L-V A) p�US� ,PHONE �+r OWVERADDRESS ,2.72'19 17_.`-!_Amilka��WL- 5,, 4-t> CITY/STATFIZIP CONTRACTOR ��YFL'�7.I�E'k-.�►'�I Amt,/ICY'-'� PHONE G{//�� ,�J�- 95-2-) ? SUBCONTRACTOR CONTRACTOR ADDRESS/ *71.I�r/ ✓Vr myz7 fe"- �—Z:� CITY/STATFIZIP 7TDCf'r TIJ'li,J X77 /5-`i ' SUBCONTRACTOR y 9 O0-e u-/4J0 PHONE C i" - �'��- YID SUBCONTRACTOR ADDRESS Iry /Yr/^r(-f 3.F, CITY/STATE/ZIP /SL 1=TDA-,>, 956'y/ I.ICENSE C.57 ❑C-61 ❑D-09 ❑Other NUMBER 22220-'/ EXPIRATION DATE , - Oji GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifd,fre—t from Owner Water System Niame ContactNamcorl`howNumbeT TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hoie O Other ❑Monitoring Weil(s)_W of wells ❑Soil Boring(s) Sof lwnng Geotechnical 2 It orhoengi ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service We])Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary XAuger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 7-0 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ^+_ ❑Conductor Casing in diameter / Conductor Casing Depth R \ Well Casing Diameter in ThicknesdGaugc/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 10 ft )dNcat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonilc(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ,Other 11 /161 ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submcmible O Turbine ❑Other HP Pump Set ft 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 bag/3-10 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 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. NIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE 5 -FF F-11 6F-+r DATE ROAD _ 17% 16 --- _ x i 15 D 2� '7 ffn 22 - - - DEPARTMENT USE ONLY ` H�gLTN DEP'°��/T,�Ik'EE Application Accepted By pp'� Date��7-1/J Area �b Employee 1D# 7"�' Grout Inspection By -fy.P4 �t81.� Date ❑ SPECIAL well Permit �l�q Pump Inspection By �7 Date ❑ WAIVER Received / Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ChecW/ Amount Date Permit/ Invoice# Well ID# Codes Into B Remitted Service R nest# 1.n / oDPlo3 l� a S Hy EHD43-0006 MASTER WATER WELL PERMIT 1222'2003