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WELL/PUMP PERMIT jL u rr 1A),f Gp., SAN J6.AQVIN COUNEY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'c kl:b STOCKTON CA 93202 •(209)468.3420 NON-REFUNDABLE PERMIT CALL 204 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED z t t2-40 r 1 JOts AnDRESS Cn'Y/ZIV UZ _ D l�1 E.f(Xl� S#tiil -�v _ a'7 _...AQ o CRUS3 STREET' _�}� --r�'Z�' APN PARCEL SIQZEp`�� -y�./• ryZ z OWNER NAME Zi(k�nn�L �c(1l�\t�`1��1�1 1 `C6,PIfONF. (��/�� 'G1I OWNER ADDRESS ,-50-a,�o11�{lJ. A�II 1.n Vr CITY/STATE/ZIP tx.',��(� 'l.,"- ica I�'7`,L ' tONTMCTOR I t(W2T2T �.f q�r� ,P�R.ONME`v1�IL,,P,�"l��"/t� CONTRACTOR ADDRESS `jJ { '1�1 ICf 7 ��1_1_/ CIT'4'/STATE/ZIP 2Q1 WQ� �CnJ 1 CP- SUBCONTRACTOR 21 (� `, PIIOVE `l u!'�-^ SUBCONTRACTOR ADDRESS 7t__�a _ l-. lAmM J Crry1SrAAn://'ZIP LICENSE U/C-57 ❑C-61 ❑0.09 ❑Other NUMBER ' iJl lJ ExPIRATION DATE 7 GEOGRAPH(CAL INFORMATION'. Coordinates X Y Township_ Rar.ge Section INTENDED USE ❑Domestic/Private O Irrigation/Agneultural ❑Industrial ❑Water Quality Monitoring E411 Sompling/Characterisation ❑Public Water Syy•tem_ _ Ir Cittevent fwm Gw�tt. over ystem ams .unma .—a PT Num •r TYPE OF WORK ❑New Well ❑Replacement WCII ❑Well Alierat—(Modipeation ❑Test Hole ❑other ❑Monitoring Well(s)_— ramb. f—ib anrcarrernar�ebs ❑C:eotechnical ra•TMn••oft-mp oil Bonng(s �)_t!1 L ❑Well Desmution ❑Out-Of-Service Well 11 Out-OtService Well Renewal O New Pump O Pump Replacement ❑Pump Repair O Cross-Connecuon Repair WELL ComaTtuCTToN � Drilling Method O Mud Rotary O Air Rotary M uger 11Cable Tool 13 Push Puin: O Other Proposed Well Depth _fl Excavation— A _ in diameter ❑Open Bottom D Gravel Pack/Gravel Size, in diameter O Conductor Casing in diameter 1 Conductor Cuing Depth `11 Well Casing Diameter_in ThickneWGauge/ASTM Sched_ ❑Steel ❑PIP.atic O Stainless Steel ❑Other Grout Seal Depth Ift 0 O Neat Cement{94 th bug/5-10 gat waver) O Saftd Cemem _ �vuck mix 17 gal water O Bentonite(20%solids) ❑Manutecturer Spec%solids,% Name_ O Specs on File O Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Othe* _ ❑Retardant/Accelerator(name)_ PEDESTAL Installed BY ❑Driller O Pump Contractor ❑Other ❑Concrete Pedestal Dlmenslons: Widthfl L—gth_.fl Thick in O Christy Bos O Stove Pipe PUMP C3 Submersible ❑Turbine ❑Other_ liP__ Ptnnplet h Standing Water Uvel R WELL DmRucriON O Open Bottom ❑Gravel Pack O Uncased O Other _ Well Diameter in Totsl Depth ft Depth to Water Il ❑Casing to be Pertbrated from tt to ft 'L` Sealing Material ❑Neal Cement f94 th lxrg/5-l0 gu/wurerJ ❑Sand Cement suckmix/7 gal water O Bentonite Pellets ❑Bentonite(20"/v solids) O Manufacturer Spec%Jsolids % Name _ ❑Specs on File O Spas Submitted ell Placement Method O Pumped 11Ll Free Fall Other jr),Z SSR Kit�L�J s (�1 O Complete with Mushroom Cep It below grade ❑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 m 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE �ryREQUIRED r�FfORI INSPECTIONS y�M SfGNED TITLE U tv 1iT l'I ILLS.{ DATE "- 7- ra It U 1 S LONLY DEPARTMENT USE LY Application Accepted By_ Date ? Area Employee ID# (Y Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By _ Datc ❑ WAIVER Received Destruction I By _ _ Date_ Construc4•d Well Depth ft COMMENTS_ 0 Se"A'e L( �l i RH f fin, I �z�(r' si/'✓t d /�i /j�,1 L1G'�!f B'i,rfL P0(.(61 --PE—T SC Amoual Received ate erm(tl Invoice# Well IDN Codes Info R,.'-Ilash B Service Request# 22 003°i 000 EHD 43-02-006 MASTER WATER WELL PERM I1- 5/7/2002