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WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY FNVIRONMFNTAI,HEALTH DEPARTMENT 304 E WEBER AVE 3""FI.-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDARLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSLED 'l. JOB AIIDRFSS 4124 CHEROKEE RD. CITY/ZIP STOCKTON, 95215 C'ROS3 S1 REE'1 AD ART RD. APN 68 7—./-10-7-2— PARCEL SIZ.: �d p :n OWNER NA:MF. RICK REED PDoNE 931-4206 ow'Nr•.RADDRESti 4124 CHEROKEE RD. CtTN/S'rATL/ZIP STOCKTON_, CA. 95215 CONTRACTOR _ NOACK _ __ PHONE 948-8817 _ CONTRACTORADDRESC 4500 E. FREMONT ST. ('ITVISTATE/L11- STOCKTON, CA. 95215__ _ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDKESS_ ('ITYISTATFJLIP LICENSE OI C-57 ❑C•61 ❑D-04 ❑Other NUMBER 504513 EXPIRATION DATE 01/05 CFOCRAPHICAL INFORMATION: Coordinates \ Y Township Ra,ige Sectk,rr_ -_ INTENDED USE K Domestic/Pnvatc ❑Irngatinn'Agricultural ❑Industrial ❑Watcr Quality Monitoring ❑Soil SampliRg/CharacLerizition ❑Public Water Systert: 11 d:lferent`ruin •x•1111: system ameConte Ti PL OF WORK ❑'New Weil ❑Repla'xmCllt Well ❑'.Veil Aiteration,MLxlilication ❑Test Ilule ❑1)Lher number of wells neuter of borings r.i nbcr of ber ing.r (1� ❑Monitoring Wcll(s) ❑Soil Boring(s) ❑Grutechnical ❑Well Destruction y❑0 Out-Of-Scrvice Weil ❑put-Of-iervncc Well Renew.I ❑New Pump ❑ Pump Replacement I!Tlunip Repair ❑Cross-Connection Repair WELL CONSTRUCfION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑other Proposed Well Depth_ ft Fxcavation in diameter ❑Open Bottom ❑t gavel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge,AST:`4 Sched ❑Steel ❑Pl:rsric [3 Stainletic Steel ❑Other Grout Seal Depth_ ft ❑Neat Cement(94 lb hug/S-l0 gal wafer) ❑Sand Cement _ iaok mr.x r 7 gal water ❑Bentonite(20%snlids) ❑Manuticturer Spec%solids c Namc — ❑Specs on file ❑Specs Suhmitted Grnut Placement Method ❑Pumped ❑Frec Fall ❑Other ❑ Rcl.rdani;Accelerator i name) PEDESTAL Installed BN ❑ Driller ❑Puntp Conrraclor ❑('[her ❑Concrete Pedestal Dimensions: Width it Length ti Thick in O Christy Roc 11 Move Pipe Pump Ob Submersible ❑Turbine ❑Othel IIP 1 Pump Set 130 It Scolding Water Level _ it WELL DFSTRLCTION ❑Open Hotiom ❑Gravel Pack ❑Llacased ❑Other Well Diameter in Total Depth 11 Depth to Water _ fl ❑Casing to be PCHoraled from (t to st Sealing Material ❑Neat Cement(94 1h hag%5-10 ba!wafer) ❑Sand Cement _ _.sack mix/7 gal water ❑Bentonite Pellets ❑Hentonite(20"o solids) ❑hlantttacturer Spec%SOIRN _—% Name O Specs on File ❑Specs Submitted Placement Method Cl Pumped ❑Free tall ❑Other — 1 ❑Co wili'Mushroom Crap_ ti below grddC ❑Gimplete to Existing Surface Pad I HEREBY CERT V 'HAT'I H',ILVE PREPARED THIS APPIACAT'ION ANP THt\T THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COU rY INAN S, STATE LAW'S, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AN ACT[ 'E W'1T THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAI' I ANI IN COMPLIANCE WITH ALL WORKERS C t NS, Tl LAW'S. MI OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS— PLEASE CALL(209)953-7697 SIGNED_ .4 . _ TmF. RETAIL SALES DATE I rn nr a= � u r� UN qOL I Lt lh E TMENT LSF.ON LV' r Application Accepted rayl;Z--- � Date 4.7—!1 `Q3 Area_ Eiriployte IDP Oroul lnspccti,rn By Date — ❑ SPECIAL Well Permit Pump Inspection B _ t Dal, 1,7 ❑ WAIVER Received Dcstructiun Inspection By _ - Date Constructed Well Depth ft CO!I.fAI FNTS PF. SC Received Amount Date Permit/ inti Ice# WeilIN4 4 Codes Info H sh Remitted Service R ucst# 2�3 EHD43'02-WO MASr8R WATER WELL PERM17 1216;2002