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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 CAIN.(209)953-7697 FOR IVSPF.CI'IOVS EXPIRES l YEAR FROM DATE ISSUED :n JOB ADDRESS /! 4�.. / /� r-►, -'7. CITY/ZIP � � 9�4� tv ri CROSS STREET �[ ' APN O Oil S ( ! Z-PARCEL SIZE 2-D►{f —LAND USE APPLICATION# ri n OWNER NAMF. ^+�_ G -- PHONE /� � OWNER ADDRESS " RSA D pin.1'./ l�r��-L^ CITY/STATE/ZIP a I CONTRACTOR G.l,�a-f-t' • _ 1 •VSO t �(.K� c I_ PHONE ',yrµ, CONTRACTOR CONTRACTOR ADDRESS 3 1 (p - �•, 'r'"'"`[r' tG-�� ✓ktYe CITY/STATE/ZIP V1D V,4G�, [LA y r /! SUBCONTRACTOR " e`er —/n `r I . PH (ONE 1C^ 'y7en}7. 7- q`y OO SURCONTRA(TOR ADDRESS�v --, x �i7 CITY/ST(�ATEJZIP "`J 1 I �1^ �"G`f// LICENSE C-57 ❑C-61 ❑D-09 ❑Other \UMBER + () EXPIRATION DATE r r 3O/d 6 ~ GF.O(:RAPITICAL INFORMATION: Coordinates X Y Township Range Section INTFNDFDUSE ❑Domestic/Private O Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ®'Soil Sampling/Characterization ❑Public.Water System __ I(different from amen aletSystem Nime TYPE OF WORK O New Well ❑Replacement Well ❑Well Alteration/Modification 6 Tcst11 e I I Vill t r ❑Monitonng Well(sl ff of wells 0 Soil Boring(s) 4 57 "u.`borm s G�( 'R"Im ❑Well Destruction ❑Out-Of-Service Wcll ❑Ouutt( ece �/G uatechpnical _red without ❑New Pum ❑Pum Re lacement ❑Pum Repair c :kjR WELL CONSTRUCTION yy/I int Drilling Method Q Mud Rotary 13 ❑ X P Q Air Rotary Auger ❑Cable Tool lr3rni tperidl Heat Mu1r ,m Proposed Well Depth I M ft Excavation.._________in diameter ❑Open Bottom ❑Gravel Pack i Gravel Size in diameter ❑Conductor Casing .. in diameter - Conductor Casing Depth ft Well Casing Diameter in Thickness./Gauge/ASTM Sched ❑Stec! ❑Plastic ❑Stainless Steel ❑Other._ Grout Seal Depth ft ❑Neat Cement(941h bag 15-10gal wate)7) ❑Sand Cement .cock mir/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other O Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other \ t ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Pump ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncascd ❑Other W Lee / Well Diameter in Total Depth ft Depth to Water ft ❑Cas; to be Perforated from _ _R t / Seating Material 'Neat Cement(94 1h hat;/5-10 Aal,voter) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on file ❑Specs Submitted Placement Method ❑Pumped Cl Free Fall ❑Other D 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 CIIRRENI' AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ATITLE <4r,-}- GeO (r0!5l,s DATE r rl JW r e 1.�.♦ i.►o. r is-k• w, "0" 1 M 1 v g• �� O VI Clr IMENT L �� • CI W r O _;"o iE LT Q N b � "4 � TG Of •fAN ,�� 1 . HUB A D AVENUE ,a i 41 1 DEPARTMENT USE O Y ApplicationAcccpted"By �fZ' -_._ Datc` c- .Area��_ F'.mployccfDft�� Grout Inspection By _._ _ Date-_ _ ❑ SPECIAL Well Permit �y Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth Ift COMMENTS -CQ,6-J 1f ! T PE SC Received QsLtec Amount Date Permiti Invoice N Well IDN Codes Info By Cash Remitted Service Request# 230 L 7J e- MASTERi lir. EHD 4702-006 r K'ATFR WILL PERMIT 1212212001