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z �� WELL / PUMP PERMIT - I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEV40p(MENT 304 E WEBER ""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA JOB ADDRESS _ yA6l9V-! 1 'rn� CITY/ZIP a 1 CC��. -)c; Y CROSS STREET R. ILA S aW. f 142- w a 0 �w� �NbF �� 'I / APN 4 —04-D--0015 PARceLSIZE p OWNER NAME }/i— � I Ll.!IVI\ IL'611�`t/ll- CDIII FLi. �K/I I �yr�PH,ONNE.r��I,i� &I� 10�-A9/3'-fii7 OWNERADDRESS 1.3/;{-� N�A,�y1 Dpi u-7 ' CITY/STATE/ZIPar µT-(urY CA7 e CONTRACTOR y�G/✓71 yy.TJ7IV I/✓/�I/li" co may Lf�S'�.IN C �,,tPHONEEy CONTRACTOR ADDRESS SON.— �I{p...1[14 /9F-c , No �� CITY/STATE/ZIP cTN l f'�Ts{I/YGI�Ljt�/ SUBCONTRACTOR pG Tj(NQ1�lpjJfTr 1 I,1✓,,ptlr,� I d �• PHONE t2�� SUBCONTRACTOR ADDRESS L/p� Ca IVC.){v Iyo�T� T--��l�i/{'y.{f- �ICIITY/STATE//ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Otheryf�+Ba9-�fp/ NUMBER �yrj Sslm EXPIRATION DATE g �✓ GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range See tion `I INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial aler Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System rs, VdifTerent from Owner, Water System Name ormetNareetef`hmasNmmlaer Il TYPEOF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other XMonitoring Well(s) L number ofwells O Soil Boring(s) numberoft,mings Geotechnical numberofbmm' ❑Well Destruction ❑Out-Of-Service Well ❑Out-OT-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION !� Drillingg Method ❑Mud Rotary ❑Air Rotary )B Auger ❑Cable Tool 13 Push Point ❑Other ��y��sP Proposed Well Depth 7—ft Excavation in diameter ❑Open Bottom )(,Gravel Pack/Gravel Size m diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched -4-0 ❑Steel ❑Plastic ❑Stainless SteelOther- V6 Grout Seal YDeepth ft ❑Neat Cement(94 Ib hag/5-10 gal water) 13 Sand Cement ,rack mix/7 gal water a, Sp Bentonite(20%solids) ❑Manufacturer Sites;%a soli ds a/ Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑FZ Fall Other [G ❑Retardant/Accelerator(name) PEDESTAL Installed By riller ❑Pump Contractor CA/r5 ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box Wtove Pipe PUMP ❑Submersible ❑Turbine ❑Other His Pump Set ft Standing Water Level ti 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 11Neat Cement(94 1b hag/5-10ga1 water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets Y-43entonite(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 I 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. MINIMU 4 Hq R Y E OT CE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 9 SIGNED TITLE DATE 11 a s y1' I 11 1 1 11 NNI H E Mr //II--��'' //��//JJ DEPARTMENT USE ONLY Application Accepted By -Ie-((�,e. Date 1//2r/�3 Area eZJ Employee ID# Grout Inspection By Date i Z,/r. ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By D'aawe Constructed Well ft elll Depth 1 COMMENTS L7ilgT � //,^,D' - I ''"-'�`I- 1 ' �8t+) II a /0� /�� 17- A.f..// �_u u✓ PE SC Received cc Amount Date Permit/ Invoice# Well ID# Codes Info By ash Remitted I oService Request# 43.65 /SZ P d.SC.v,) �� 1 O /y' EHD 43-02-006 MASTER WATER WELL FERMI 12/6/2002