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WELL/PUMP PERMIT <br /> SAN JOAQU W COUNTY ENVIRONMENTAL HEALTH DEPARTME`:l600 EAST MAIN STRux-STOCKTON CA9S202-(209)46$-3420 <br /> NON-REFTINDABLEPERMIT EXPIRES 1 YEAR FROM DATEI n <br /> Jos ADnutyss SA L <br /> CROSS STREET c 0"A(_, At11 1 C j APN1-i�:�1 Q10 PARCELSIZZ a a• a� U v �� <br /> OwNERNAME 9ABkA�rv_ PHONE <br /> r" AR <br /> OWNLaAmuitm h)Jlz_ <br /> _ � 1 CITY/STAWMP `k132020 3ZO(O <br /> CONTRACTOR &jl9� r��sN�qL <br /> CONTRACTOR ADDRESS )/ (.y ,�- =dRV/C6 c <br /> ry <br /> SUBCONTRACTOR - PHDNE ___ <br /> SUBCONrRACTORADDREss ___—_ CrrY/STA1rrr14r __..___. <br /> LICENSE ❑C-57 1 O D-09 O Other NUMOER EXPIRATION DATE <br /> GEOGRArmCALINFORaf T&ON: Coordinates X Y Township__ Range Seetlw <br /> lntanmeol)se O Domcstic/Privatc ❑Irrigation/Agricultural stria) O Water Quality Monitoring O Soil Sampling/Chamclerhaatkm <br /> OF .Water Sem---- — A <br /> Ildifi �: w.w sr�%n,nanx: Couacl Name a Pnnnr Number E ENT <br /> TYPE OPWfsRIt ONew Well ❑RephcenantWell OWell AlteralionJMtdifitanion OTa ❑ <br /> Test Other_ __ _ <br /> _.____—_—._. _ /1,� <br /> numberofwat <br /> uacofbari� ❑(❑Monitoring Wells) 13 Soil Boriag(s) 'CotCCh'n,Cal____ <br /> OWell ❑Out-Of--Service Well Renewal -- <br /> n••m1+-uEb<-ing. pAR <br /> ❑WPRlmc ❑Cs-CoctionRr <br /> ZZOWLLLCOSTRUCTION qNJO <br /> Drilling Method ❑Mud Rotary ❑Air Rotary O Auger O Cable Tool O Push Point O Other _�� Q/'/N C <br /> Proposed Well Depth R Excavation _in diameter ❑Open Bottom ❑Grovel Pack/Gravel SPoe_ TLA V OU <br /> O Conductor Casing in diamotcr 1 Conductor Casing Depth R EPq R <br /> N M,rj �rY <br /> Well Casing Diameter_m Thickncss/Gauge/ASTM Sahcd O Steel O Plastic O Stainless Steel O Other rl ySN r, <br /> Groat Seal Depth ft ❑Ncat Cement(94 lb bag 15-10gal%vier) ❑Sand Cement _sack mir/7 gal water <br /> O Bentonite(201Y.solids) ❑Manufacturer Spec%solids—_% Nam O Specs on File O Specs Submitted <br /> Groat Placement Method OPurnpod O Frce Fall O Other ❑Retardant/Aecclaretor(name) <br /> PEDESTAL Installed By ❑Driller O Pump Contractor D Other _ -- <br /> ❑Concrete Pedestal Dimensions: Width_ft Length_ft Thick in O Chrirty Be, O Stave Pipe <br /> PUMP uhmersible ❑'rurbinc OOtber HP-7&— Pump Set ft SandingWaW1&vd ft <br /> W Eu.D/.SfRUCT N O Open Bottom ❑Gravel Pads ❑Utrcased O Other_ <br /> Well Diameter_in Toa)Depth B Dcplb to Water _ft ❑Casing to be Perforated from_^R to ft <br /> Sealkrg Material ❑Neat Cement(941b bag/5-10 gal%vrer) ❑Sand Cement .rack mit/7 gal water O Reatoohe Pellets <br /> ❑Bentonite(2p/o solids) ❑Manufacturer Spec%solids % Name_ __--- O Speca on File O Specs Submitted <br /> Phcemeat Method ❑Pumped 0 Free Fall ❑other. <br /> ❑Complete with Mushroom Cap ft below grade O Complete to&i istug Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN CO ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND TIVE IRE C AFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT f AM LV COMPLIANCE WITH ALL <br /> WORKERS co. N WS n <br /> --- TITLE <br /> Ill U'r <br /> IA <br /> V <br /> . <br /> DEPARTMENT T U E O.)LY / <br /> Application Accepted By /4", _ Date /Z070 Arca '� Employee ID#_✓KIY 4 <br /> Grout Inspection By Date SPECIAL.Well Permit <br /> Puropinspection By ,.;s la > +- t7ato 0 fit. 0 WAIVERReceived <br /> Destruction Inspection By Date_ Ceestructed Nell Depth ft <br /> COMMENTS - <br /> PE SC Reratved C Amount Pernow b,�# Won TDO <br /> Code; Info Remitted h Service ReatlatM <br /> O!go 7 <br /> EHD 43-02-006 WEB heli Permit and Dmiararion.doc <br /> 9/11/2007 <br /> , d <br />