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SY ( ,q( (,oPIl �Il� WELL / PUMP PERMIT SOAQ61N COUNTY EM1'VIRONMENTAL HEALTH"'ARTMENT 304E WEBF- vE3R"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT VCALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED (A 9 � vv ; RNF R a }� JOB ADDRESS n CITY/ZIP ` n eQ I F o CROSS STREET L ✓w��T ��/ `L /� � � / J F� � APN PARCEL 512E m OWNERNAME _}AY\— '�^r k/r. Q /\ PHONfEs I� 1J16 w �— �t 7. � N OWNER ADDRESS AlI ✓'f^ [ i ��tAl�„ "/��• CITY/STATE/ZIP 1 �111p� LA s } y 7 CONTRACTOR A 1 C /'S }Jp). rFA L 1- S AL AI ^,PHONE -f L rl�r+�_\_/y_J CONTRACTOR ADDRESS 7, Jl� I Il1Uf ✓� 7T�� CITY/STATE/ZIY IV. LIIGH III rL,Jc��p� �. SUBCONTRACTOR 4 rr N 1�L ! {{ [11r�u LA L I AI PHONE 1`1l b) to j I .e ) 6 li SUBCONTRACTOR ADDRESS C �� .7 LNA 1 �� CITY/S TATE/ZIP sA c�t A�/- A- '/l c>q �7'r! LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER lO�< 7 EXPIRATION DATE /'?U/4'/,7 GEOGRAPHICAL INFORMATION: Coordinates X Y Township 11"/ Range_aT_ Section_ INTENDED USE ❑Domestic/Private ❑IrrigatiodAgricultumi ❑Industrial `Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System mer Ifdifferent from Owner: mer ystem ame ontan ame or P one u TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other mber of wells number of borings number of borings ❑Monitoring Well(s) nu ❑Soil Borings) ❑Geotechnical Well Destruction, Out-Of-Service Well ❑Out-Of-Service Well Renewal eve E] -Connection Repair Nn? Pum Repair ❑Cross WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth H Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ti Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib hag/5-10 gal water) ❑Sand Cement sack ma/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 R Length_ft Thick in.. ❑Ch$i§ty Box U Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pu In Set - Ott Standing Water Level Ie I a- R WELL DESTRUCTION ❑Open Bottom ❑GravelPack11U��cased�./ I ❑Other Well Diameter_7 in Total Depth _ 34.. ti Depth ta�Water_��ft ❑Casing to be Perforated from H. to IT Sealing Material Neat Cement(94 lb hag/5-I0gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method Apumped ❑Free Fall ❑Other Complete with Mushroom Cap A 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Xj, MIINJIM 24 HOUR ADVANCE NOTICP REQUIRED FOR INSPECTIONS / SIGNED .l1Nfq./ 6/ A TITLE DATE ! 1, l IJ C-' I L I ry DEPARTMENT USE ONLY /- Application Accepted By - - - Date•-Fr�(;` _^ ' .Area EmployeelDN Grout Inspection By Date r ❑ SPECIAL Well Permit Pump Inspection Byff Date ElWAIVERReceived - Destruction Inspection By 4t&At a-e Date 0 Constructed Well Depth it COMMENTS rnj ,f( /—M L/IAf/�^[.t' .(' e,.: r7� ASLO PE SC Amount Check#/ Received Permit/ Codes Info Remitted Cash gy Date Service Re uest# Invoice# Well 1D# 3501 4t', 0 - �Y ni Saoo3zlo EHD 43-02-006 MASTER WAl'ER WELL PERMIT 5/7/2002