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WELL/PUMP PERMIT r ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL I'll DEPARTMENT 600 EASTMAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-RERUNDABL]EPERMIT �q)ucL'16q�rnrz lvsPr. EXPIRES III YEAR FROM DATE ISSUED IISSUEED Jon ADDRESS !/ /O �/'/✓✓rT/V _�/L-_- . CrrV/`,LIP CROSS STREET S /nom/] APND S,Z�'OPAR�M SIZE OWNERNAME `�aS" '/V `-,� .. __l/�F��yyyC�ttll��1'Y/STA7Y//�7/Jf y�J /fit CONTRACTOR -' "� ✓r� G✓` vL //-6 TIIONE CONTRAC[OR ADDREtI6�/'�`� S�W� Z(9 CITy/$TA7q//jf ��-/ ✓/ �I�L� /SL-✓ Z SUBCONTRACTOR - PHONE 1.1 ECC"L,,, ADDRESS CrN/STATEDZF57 C-61 0 D-09 O Older NUMBER ' a E%PIRATION DATE JAN0 9P/IICAI.INFORMATION: Coordlutes X Y Township_ Range Sectim N7'ENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 13 Soil Sampling/Chamctevetion ❑Public Water System ENVIRONMENTL HEALTH IfdiR oraoa,o,.�ar: — Wa«Sy"_Na_ CasarzNa—.M.-Nmnbc, -- -- PERMIT/SE E WORK ❑Now Well 2cplacement Well ❑Well Aftelation/Modiecation ❑Test Hole ❑Other ❑MORitor(ngWell(S) -*—f-11, 0 Soil Boring(s) Onutwoftmings [3G.W.1Rical p1Q1boftorisp ❑Well Destruction ❑Out-Of-Srnice Well ❑Out-Of-Service Well Renewal ❑New Pump XPumpReplacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary O Air Rotary O Auger ❑Cable Too] ❑Push Point 0 Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size ie dbmdw ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter—in Tbickness/GaugdASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Ncat Ccment(94 Ib bag/5-10 gal Raster) ❑Sand Cement sack mar/7 gal water O Bentonite(2(rsolids) ❑Manufacturer Spec%solids^% Name ❑Specs on Fite O Specs Submiucd Grout Placement Method ❑Pumped ❑Flee Fall ❑Other 0 Retardant/Accelerator(name) PEDESTAL Installed By ❑Drillcr ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width _ft Length_ft Thick in ❑Christy Box O Steve Pie Pumr ubmcrsiblc ❑Turbine ❑Other__ HP Pump Sb Standing Water Level ft WELL DE:SI'Rvci for, ❑Open Bottom ❑Gravel Pack O Uncased ❑Other Well Diameter------in Total Depth ft Depth to Water___ ft ❑Casing to be Perforated from itto ft Sealing Material ❑Ncat Cement(94 1h bag/5-IOgal anter) ❑Sand Cement-._--__—wk mix/7 gal water O Bentonite Pellets ❑Bentonite(2tPo solids) O Manufacturer Spec%solids_-°b Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall O Other-- _-- ❑Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad 1 HEREBY CERTWY THAT I HAVE PREPARED TMS 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 ACTIVE WITH THE CAIJFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. UR ADVANCF.NOT1CF RF.QUIRFD FOR INSPECTIONS SIGNED /' ` TITLE / moi/ -- --F-- ---- - ------- SqN✓0 > 2020 h�TH�OpVC gFNTACN� 14-0 oll RTMFNT D ARTMENT U Application Accepted B Date Z� Ana Employee ID# Grout Inspection By { Date 0 SPECIAL Well Permit Pump lnspection By 4"V L.5� �� J `6 Date Iq 2�o O WAIVER Received Destruction Inspection By Date CoodnicEed Well Depth_ _ft COMMENTS PE SC Received Amoout DaftPaf� Invoice# Well iD# C m Info Caen milted K EHD 43-024)06 WEB Wrll Permit and Dectararion d- 9/11,2007 • r