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WELL/PUMP PERMIT SAN JOAQUIN COUNT)EN\'IRONNIENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-rl.-STOCKTON CA 95202-(209)468-3420 NON-RErUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR PROM DATE ISSUED SCSI t[17�,a:r-iT7T�Cc rn/r.rZ,t t - / I�f t Ltc..+.S�r'TTrrx.f'u\- f S/uv eAgyfa,J Cer.r..�"i'y' v_ JOB ADDRESS `�-O.V 6• )L �Ya� �1' /�T�� CITY/ZIP _ p C CROSS STREETi 7'/ /'r ANN OL,I-rl—7 —/1-721L E PARCESI% OWNER NAME `,C I\/y 1/kA Lj f-ZyA-1 L PHONE CZLXI )33+ �j r /� r- O\VNER ADDRESS }+�I�- `r�31(�Fl� �f-1 C=� 1^LR d CITY/Sl'ATFILIP Zl<<! , C//�i �I7/Z��-1C 1� CONTRACTOR Nl t..'1 t (('�� PHONE��I -/r 2-1- CONTRACTOR -1/• CONTRACTOR ADDRESS 3:) '2-1 Co C4I,,- T" j F-iA[-1F�L'CITY/STATEILIP ja(.I2AtLn.TI�+ cm -r�,f�•,}LL- � SUBCONTRACTOR SPr C7r•7llffn 1� '- 'fw;fin;L , PHONE. �'Cti- �Y C-S- x_773 SUBCONTRACTOR ADDRESS 'Z 7 n,.,1/)l'L'v CIT)'/STATE/ZIP SI7: LA SIS LLf-S LICENSE -57 0C-61 0D-09 ❑Other i\UaIBERLS• -SIZZ4:Q E!(PIRATIONDATE CEOCRAPHICAL INFORJIATION: Coordinates Y Y Township Raange Section INTENDED USE ❑Domestic/Private 11Irrir Irrigation/Agricultural ❑Industrial 94- -ater Quality Monitoring Ia Jnil Sampling/Characterization ❑Public Water System If dufe-v from i)amr .oar Sy- N.i C,nuaai aina or Mlona.um r TYPEOFWORKWell ❑Replacement Well' ❑Well Alteration/Modification 13 Test Itole ❑Other ❑Monitoring Well(s) amber-.(well, p Soil Boring(s) nwnberurbmhiga ❑Geotechnical nan,berorb-,.p ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum E3 Pum R lacemeot ❑Pum Repair ❑Cross-Connection Repair WELL COKSTRUCI10., St !r/1 L 1,0"1 D fA VI-/tr r-, Drilling Method ❑Mud Rotary ❑Air Rotaryager ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /U(i fi E<—.non a in diameter ❑Open Bottom Ptravel Pack/Gravel Size 7- 1 Zin diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft -377.1— Well Casing Diameter 2,S in Thickness Gauge/ASTM Sched 'fCJ Pt✓e ❑Steel 13•Iflustic ❑Stainless Steel ❑Other Grout Seal Depth D-SS ft t2r�.c Cement(94/bhug/S-/Ogol,carer) ❑Sand Cement .rockmit/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method uniped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ].{filler ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_fl Length_ft Thick in O Christy Box 113'ftove Pipe PUMP ❑Submersible ❑Turbinc ❑Other IIP Pump Set ti Standing Wager Level li WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth Il Depth to Water Il ❑Casing to be Perlbr led from fl to It Sealing Material ❑Neat Cement(94 1h hug/5-10gal,varer) ❑Sand Cement serck nrir/7 gal water O Bemmnitc Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 0 Free Fall ❑Other ❑Complete with Mushroom Cap li below grade ❑Complete to Gxisling SIIflacl•Pad I 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. 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. 691NIN1UM 24 HQyR ADVANCE NOTICF.RF:QUIRF.D FOR INSPECTIONS SIGNEDICZavi�/lI/� ( �r TITLE St'.+1ra✓- �-1tr�lEr,e EM ziB e aazJ� ♦♦��(, ;f ee ''ii W1 InViJI A 01 o ® :y5 3 :� ) zrA, Ifs ifs �,Jl} r •,f _ ry , vl Y•4'� r`W `i r UN I I :_ �`,�'�� e� 'j•Y ry+!A3:,, t r^J'�J4 � 11r Application Accepted By ,�111m ey,T_11® d,.I,ta rsrca P Yc'e Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Amount Check#/ Received Permit/ Codes Info emitted Cas-b g D•to Service Re nest N Invoice N Well IDN /(JZ EHD 43-02-006 MASTER WATER WELL PERMIT 5nnom