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WELL/PUMP PERMIT SAN JOAQVIN COUNTY Eml RONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMITCALL.(209)953-7697 FOR INSPF.('TIO%S EXPIRES 1 YEAR FROM DATE ISSLED - u. JOB ADDRYSS �. GtJO U(f ,t 12 1. ! crrYruP _ AC-Cen-) 70 1. 6A 95 27-0 a i CROSS STREET 'KPYI/I g-T t C�1c APN 01-7-09 O'S S PARCEL SIZE F 1 GWNERNAME9n6,1114 /74010o1/1 -C z OCrlt/�o1.1 PHONE ('zoo) 369-5$6L OWVERADDRESS 574 YYIC CITY/STATE/ZIP CONTRACTOR Tim CYRYIIAel 1 PHONE. � CONTRACTOR ADORESS _ CITY/STATE/ZIP �O-'t SUBCONTRACTOR PHONE _-_T_- 1• SuaCON TRACTOR ADDRESS CITY/STATVZIP LICENSE O C-57 O C-61 ❑1)4)9 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates Township Range Section Q I INTENDED USE O Dumestic/Private O lrrigatiun,Agricuitural O Industrial O Water Quality Monitoring O Soil Sampling/Chamcienmtion O Public Water System _ Cea 7 p j ifewri rt w—, tie[ Rett yskm oma tion amew ion. r _ TYPE Or WORK 13New Well O Replacement Well O Well Alterittion/Modification O Test Hole El Other Other _ O Monitoring Well(s) °"abater»dU O Suit Boring(s) ^°'"�vrb"rhe O Geotechnical ❑Well Destruction yl M,of-Service Wellg0(/,%k C3Out-Of-ServiceWell Renewal m O New Pump O Pump Rcpiacemcnt O Pump Repair rial'1 ❑Cruss-Connection Repair WELL CONS I HUCTION e 1 Drilling Method O Mud Rotary O Air Rotay O Auger O Cable Tool O Push Point O Other d Proposed Well Depth _h Excavation _in diameter O Open Bottom ❑Gravel Pack/Gravel Sia- in diameter O Conductor Casing in diameter / Conductor Casing Depth __ _h Well Casing Diameter__in Thickncss/GaugelASTM Schad O Steel O Plastic O Stainless Steel O Other Grout Seal Depth P. O Neat Cement 194 Ih hug/540 gol water) O Said Cement .reek mix 17 gal water O Bentonite(20%solids) O Manulacturcr Spec%solids_% Name O Stites on File O Specs Submitted 3 Grout Placement Method O Pumped ❑Free Fall O Other__ O Retardant/Accelerator(name) O PEDESTAL Installed By O Driller ❑Pump Contractor O Other _ O Concrete Pedestal Dimensions: Width_fl Length_H Thick in O Christy Box O Stove Pipe PUMP O Submersible ❑Turbine O Other HP Pump Set. II Standing Water Level It WELL DESTRU(TION O Open Bottom O Gravel Pack ❑Uncued O Other i Well Diameter_-in Total Depth R Depth to Water ft O Casing to be Perforated from__ h to__— h Sealing Material O Neat Cement(941h hag I J-10gal Kvier) O Sand Cement .tack mi.r/7 gal water O Bentonite Pellets ❑Bentonite(200/.solids) O Manufacturer Spec%solids_o/ Name O Specs on File O Specs Submitted Placement Method O Pumped O Free Fall ❑Other _ _... O Complete with Mushroom Cap __ R below grade \ O Complete to Existing Surface Pad 1 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS , CURRENT AND ACT4VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIIVWM}y HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(N)9)953-77697 SI(.NF.D( �yf ! __ TfTLE 1 /G(J f PC.T /e T A�A C�_�tC DATE 7 - y v I I I j i IIIA 4:1 1.7 I 5 , IV i A HE LTV D. �s �y"fit DEPARTMENT USE ONLY Application Accepted By A7 �M Date -6"3 _- Area Employee IDk __�Q_ Grout Inspection By _ Dae _ ❑ SPECIAL Well Permit Pump Inspection By ___. Date_.. ., ❑ WAIVER Received Destruction inspection By_ Date Constructed Well Depth _h COMMENTS PE SC I Received .Chet Amount Date Per t/ Invoice N Well IDM Codes Info By as Remitted Service Request M 36 I-7 5 -v 1 YlLu T6, 1 �S EHD 43-02-006 - MASTER WATER WELL PERMIT 12/612002