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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 DATE ISSUED L/ �} / M JOB ADDRESS � ` 'may �/�-ey. d(Ir( CITY/ZIP / / it-� _ �� CROSS STREET �� APN 0 PARCEL SIZE 3 r �+ [ OWNER NAME � ! � ``r F 6 L.U / "� S-16, PHONEE� .96,F OWNER ADDRESS -'`G� � e/ -15- 3240 I �J CITY/STATE/ZIP ��t 7 1 ` j� r 5— 324r0 CONTRACTOR _ _ '�( [ >°� PHONQE�y��+ f— CONTRACTOR ADDRESS � - CITYISTATE/ZIP "' �s+C. ``Pr � E�• �v SUBCONTRACTOR ��[�.I-!!� PHONNEq, 20!2— SUBCONTRACTOR ADDRESS _ �(.s� (�tffl�yQf�'i�,(/iZ (J� CITYISTATFJZIP !'�C.� J LICENSE C-57 ❑C-6l ❑D•09 ❑Other NUMBER 5 EXPIRATION DATI„ ( �� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System if dirFerent Fromowner: Waler System Name Coniaci Name or Phone Number TYPE OF WORK ❑New Welt ❑Replacement Well ❑Well AltemtionlModiftcation ❑Test Hole ❑Other numher of wel Is number of borings number o f bori ngs 13 Monitoring Well(s� _. ❑Soil Boring(s) ❑Geotechnical Well Destruction 13Out-Of-ServiceWell ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Re lacement ❑Pump Repair _ _ ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Poirt ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASI'M Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seat Depth ft ❑Neat Cement,94 lb hag/5-10 gal water) ❑Sand Cement .suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Ret rdant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine El Other HP_ Pump Set tl Standing Water level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack 7 Uncased FOther Well Diam ter ;Z in Total Depth 36�'N'ft Deptb to Water �4 ft ❑Casing to be Perforate from ft to ft Sealing Material WNcat Cement(94 lb bag/5-10 got water) El Sand Cement sack mix/7 gal water 11 Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids _ % Name E�Specs on File ❑Specs Submitted Placement Method Pumped 11Free Fall 13 Other_� I�� C .Lig 1f #d !s�Cl,r e ❑Complete with Mushroom Cap ft below grade Wcomplete to Existing Surface Pad 1 HEREBY CERTIFY THAT I 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. MINI M 24 HOURRiAD NCE NOTICE REQUIRED FOR INSP C/T1 iOrNS— PLEASE CALL(209)953-7697 SIGNED__ �� /� `�� TITLE ( (.OM1 l DATE '.�" �•: °' .tt_�. WwgNF GSYx n rdn r OMNT ; LINeg. � i1oAo �"'� �1F1I�,y i 'GRANT ~} LINE AO! Nuq I J a � 1 ldH AQ TWEN eC 3r.mi IT ERIT TYfENrM9FYAM0 3 } 5•a ST TWENT% a ST AST TWP TriFIA$T ST z R d C NePEAF 9 a uuq,EVW �I `Tev,oc" e w m �WtST 7WENTIE ST, Eil9T TWENTI.RH ST. Sn er. WC EA" •s 6 A MREIRA A . S G LL -EST WMITTIER a 3 n'FCr un, Ir1LTpGL -EST EWh` A4E wNITT1EA AVF cLu� -ENs� c ENER50n AVE, -v NILE WEST �LOwF LL Av WWRIf htlF�•' AYFMIE WEST "�Lde AVE. AVE WEST IDWELL - G v, _ ACACIA sTAE G - LInOa PL, Plm gGM1 cT .v? wvVah wEET s CAA LTGN w Y FFoanL -. NaCl Rq LIN PL CAITln AYE E y EAST FVERL PL CE i -LACE ; W. BEVERLY qL, ; A grinCr WLL" AVE-¢ 2 WE 7 EAT � FAST $ EATCN 31v ,� 1 ALAI Z a x IWfly ql _ Mi s O 3u t F ¢ W J ENNF S IGNL XD AUC. -r , LFT"ET r t - 3 Rv RAY ApU fwCLP N gT, ; ,Fn S1- aLrA Fleur ry WEST L CFFTN ST T ■ ry� S of p "L 'to TENTN oe N Z SAT- OIIE f DEPARTMENT U E ON Application Accepted By Cff 1 Date �'3 d Area Employee ID# ` Grout Inspection By Date ❑ ESPECIAL Well Permit Pump inspection By / Date ❑ WAIVER Received Destruction Inspection By / _ Date � !- q Constructed Well Depth n COMMENTS PESC Received Check#/ Amount Date ermit! Invoice# Well!D# Codes Info B Cash Remitted Service Re nest# Sa b EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002