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q ill" coe I� WELII"l PUMP PERMIT S%$' JIDAQNNCOUNTYE VIRONMENTALHEALTHr! ARTMENT 304E WEBF--�VE3 'FL-STOCKTON CA 95202 - (209)468-3420 I NON-REFUNDABLE En PERMIT � F,�rCALL 209 953-7697 FOR INSPECTIONS XPIRES•1 CA FROM DATE ISSUED JOB ADDRESS _9.0, w. 9 V, .yt� T(�I/Q/y/ R - CITY/ZIP 4M11 C A q � 2 C�{ m CROSSSTREET LQ/W_:kf'" f,4�A M/-A' / /J IJ APN A PARCEL SILE F OWNER NAME p,l '" /� 'r /I /PIION(E� ` 6/ )l .��rp -�r91 7t ) rA OWNER ADDRESS /-�/V 1 T_m/`/ya J�( R^/�! CITY/STATE/ZIP 4-L)A I l�\I� �7[r� `f'0 CONTRACTOR y1_c/'{sdc.,A (/C .J I/VL �p1I ! .� J /- f��'•7�^7 /r,PHONED r/A10�/ 1 �t �/ / CONTRACTOR ADDRESS3tn.�7c� `MAD) 5/J�N/ Adrt'1 ' '1" CITY/STATE/ZIP !Y, ��'UH(I"1/"�.l �A / [SUBCONTRACTOR —M ITLH/' LL [ JjJ�I��1��(,,.�L+i./-V,e{, PHONE �y��) (,3t-.�.r��3 SUBCONTRACTOR ADDRESS S3 W) s yy t y t{II� CITY/STA/TE/ZIIP/5AM &), AA-Tu, cel jazz LICENSE _ "C-57 ❑C-61 ❑D-09 ❑Other r e NUMBER L6 M_ rp 1 / EXPIRATIONDATE VJ/�V/(�•� / GEOGRAPHICAL INFORMATION: Coordinates X Y Township i ly Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑IndustrialWater Quality Monitoring ❑Soil Sampling/Chamcterization ❑Public Water System I Ifdife'rem from Owner: °mr ys�em ame - onmcl °me or one mortlel TYPE OF WORK ❑New Well ❑Replacement Well O Well Alteration/Modification ❑Test Hole ❑Other number of wells gs number of borings ❑Monitoring Wells) 13 Soil Boring(s)s number of boring g( ) _ ❑Geotechnical Well Destruction �''j ❑Out-Of-Service Well ❑Out-O(-Service Well Renewal ❑New Pump um ❑Pum Re'lacement ❑Pum Repair ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth N Excavation . in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _in Thickness/Gauge/ASTM Sched 11 Steel ❑Plastic 13 Stainless Steel ❑Other Grout Seal Depth 1't - ❑Neat Cement(941b hag/5-10 gal water) ❑Sand Cement nock mLr/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller- ❑Pump Contractor ❑Other �� ❑Concrete Pedestal Dimensions: Width_ 11 Leogth_ft Thick in d ❑,rClf-r1§t^fB6z ©.Stove Pipe ' PUMP ❑Submersible ❑Turbine ❑Other � _ - � lu HP r Pur ,PS ' ft Standing Water Ce,,rvell) WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑U��jjCga//ced L,, I ❑Other Well Diameter�in Total Depth�1 ft Depth MaterZ¢/. it ❑Casing to be Perforated from ft to It Sealing Material Neal Cement(9411,bag/5-10gal water) ❑Sand Cement rack mix/7 gal water ❑BentonitePellets ❑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 - I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN j JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �MlM�244 HOUR ADVANCE NOTIC REQUIRED FOR INSPECTIONS. SIGNED 6/ ! ( TITLE DATE -1 C7T 44 ......,- ,....,. . , -. . ------------ i I DEPARTMENT USE ONLY Application Accepted By J>!Ir-_,°Ty,�l;.0 .�„s--`-., ,=r,:�••-"Y.=. -Dates-{{�S s": - G., :_„..rArea,�" s'•-- *.- Eruployee IDN�'- IF— Grout Inspection By Date r r ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received. Destruction Inspection By 4W110_1ft Date IT , U Constructed well Depth it COMMENTS 3 J PE SC Amount Check#/ Received Date Permit/ { Codes Info Remitted Cash By Service Re nest# Invoice# Well IDN 35oz 0- 0- l Lk i ria 1;02nv37.16 EHD 43-02-006 - - MASTER WATER WELL PERMIT 5n/2002 , 'r