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WELL,/ PUMP PERMIT - - SAN JOAQUIN COUNFY E.s'I RO.NMENTAL:HEALI II DEPART xIENT 304 E WEBER A VF.1M°FL-STOCKTON CA 95202 -(209)468-3420 NON-RFFUNDABI,E PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM gDATE ISSIIF.D JOB ADDRESS 5 9 1 C, F. /tel L•!('t1d�J+'. e �l f _ CITU'/ZIP 4`!! !!�(? CA / Z-'_O CROSS STREET - APN 0 r7 U9 — __ PARCEL SIZE. OWNER NAVIF. _I.r./el� lF n . -- PHONE OWNER ADDRESS SCI CITY/STATE/ZIP_ .I QiJIG COQ\rRACfOR CO!VTRACrOR ADDRESS CITY'/SPATE/ZI P SLBCONTRACTOR PIIONF 1 SURCONTRA(:'rOR ADDRESS CITY/SMTE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Othcr NUMBER ExPIRATION DA7'i:__ CLucRAPit[CAL INFORM nnoN: Coordinates X l' Township- Range Section__ INTLNDED USC ❑4 Domcstic'Privere ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Sud Sampling'Chaacicrizuti on j , I(AiRerent from er crliysem Fran - —Za fu rP�i) T -Itp--- T TYPLOFWORK onTLirFa�r11/e_(� _. I ❑New Well ❑Replacement Well ❑Well Alteration/Modilication ❑Tc-sr Hole ❑Other - umher o(w,tlt umber Dr Iwnii•• ❑Monitoring Well(s) ' ❑Soil Borings) ° '' ❑Geotechnical "umhnr of bmmgs i 13 Well Destruction Out-Of-Service Welibjt IJ 2 ❑Out-OI`-Service Well Renewal ❑New Pump ❑Pump Replacement 0 Pump Repair ❑Cross-Connection Repair WELLCON$rRUt.TION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Oiher Proposed well Depth tl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size m diameter ❑Conductor Casing _in diameter ! Conductor Casing Depth It Well Casing Diameter_ _in Thickness/Gaugc!ASTM Schell ❑Steel ❑Plastic ❑Suinless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94 1h hog/S-10ga1 wore•,) ❑Sand Content_ .cork ori r/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on Pile ❑Spres Submiued Grout Placement Method ❑Pum ❑Free Fall ❑Other r Pc'd ❑Retardant/Accelerator(name) PEDESTAL Inctalled By ❑Driller ❑Pump Contractor ❑Other_ ❑Concrete Pedestal Dimensions: Width_ft Length_It Thick_ in ❑Christy Box ❑Stove Pipe Pvvir ❑Submersible ❑Turbine ❑Other_ HP__ Pump Set it Sanding Water Level _it WELL DESTRUCTION O Open Bottom ❑Gavel Pack ❑Uncased ❑Other Well Diameter_in Total Depth _it Depth to Water_ it Cl('astng to be Perforated trom__ft to_ O Settling Material ❑Neat Cement(94 Po lxrg/5-10ga1 swtrrr) ❑Sand Cement__ suck Tarr/7 gaI water ❑Rcntumte Pellets ❑Bentonite(20°o solids) ❑Manufacturer Spix%solids "/, Name ❑Specs ou file Q Specs Submitted Placement Method ❑Pumped ❑Frce Fall ❑Other_ ❑Complete with Mushroom Cap_ It below grade ❑Complete to F-xistiug Surface Pad J I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOVE IN ACCORDANCE WITH SAN JOnQUW COUNTY ORDWANCFS, 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 I nM IN COMPLIANCE WITH ALL � WORKERS COMPENSAT NLAw'S.AWS. M l 24 H GR ADVANCE NOTIC , EQU1R D FJQ�(/]INSPECTIONS o SICNCD _ _ Tirt.e_ ' / DA rE i I I 4-0 N Y ."c rt S� n.S310N _ DEPARTMENT USE ONLY' - - - — - - -- -- - Application Accepted By Nt!•1 pate -•�YOZ Employee fD# 5�0 Grout Inspection By_- _ Date ❑ SPECIAL Well Permit Pump Inspection By Date— ❑ WAIY'F.R Received Destruction Inspection Ry pate - _ Constructed\Nell Depth ft COMMENTS PE SC Amount Check#/ Received Permit/ Codes Info Remitted Cas By. Date Service Ra oast# Invoice!! Well IDD uw, 31 ! c o0 zo8 iol5�j F.H D 43-02-006 5/72002 MASTER WATER WELL PERMIT