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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENNIRONN ALT.DEPARTMENT 304 E WEBER A -STOCKTON CA 95202-(209)469-3420 ' NON-REFUNDABLE PERNII T CA LI.1209)9i3-7697 Foil INSPECTIONS ES I YEAR FROM DATE ISSUED y ' �'.QQtbi l l T. CITY21PT n& CA — R JOB ADDRESS andfi 1 L*Fi4�4 WavArl�� R� ��,,�,�-- —�� b Fe CROSS STREET F 4 Road APN PARCEL SIZE i OWNER NAME Co PHONE 209-468-3066 o u l c W r SCITY/STATE/ZIP Stockton, CA 95201 OWNER ADDRESS CONTRACTOR M^r+.im-T T Water gyStimmS jnr _ PHONE(925)432-42 CONTRACTOR ADDRESS 1818 Loveridge Road CITY/STATE/ZIP Pittsburg,CA 94565 SUBCONTRACTOR N/A PHONE SUBCONTRACTOR ADDRESS CRY/STATE/ZIP LICENSE XC-57 :6 C-61 ❑D-09 [IOther NUMBER 510952 EXPIRATION DATE 5-31-05 _ GEOGRAPHICALINFOR)IATION: Coordinates X Y Township_ Range Section INTENDED USE ❑Domestic/Private E3Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferentfrum 0—er Wate,Syn— am ami Contact um T1PE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/lOodification ❑Test Hole Other' tiumTier;a M and> numof wells ❑Soil Bonn s number ofbonngs [3 Geotechnical Monitoring Well(s) her �_ Boring(s) ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Re air ❑Cross-Connection Repair See ,r4wl.k NN'ELL CONSTRUCTION Drilling Method ❑Mud Rotary )(Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 250 ft Excavation 4 in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casin Depth ft Nk'ell Casing Diameter Win Thickness/Gauge'ASTAI Sched r'G4 Yy ❑Steel )(Pl.uc ❑Stainless Steel ❑Other — yE, k mix 1'7 gal water Grout Seal Depth � R cat Cement(ya lb bug S-/0gu/a�urer) CI Cement sac _ ❑Bentonite GO,.solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑Other 11Concrete Pedestal Dimensions: Width_ft Length_ft Thick in ❑Christy Boz Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other � HP Pump Se[ ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Seating Material Cl Neat Cement r)4/b bag'j-/Ogul tcater) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(2G4'o solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ;}fl ❑Complete to Exis ❑Complete with Mushroom Cap ft below Existing Surface Pad l� 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORT:WILL BE DONE IN ACCORDANCE WITH SAN W JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS t3N CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE, BOARD AND THAT 1 ANI IN COMPLIANCE WITH ALL NYORKERS COMPENSATION LAB'S. NIININ11 -N!2 IIOI'H ALA ANCE NO]WE 1IItflQ1 llu:t)GOft i\SPt(('"I 10:S `^ SIGNED TITLE /( r e-S-/de V.-A— DATE V_:Z '0 ss EDIT IVED lulN CC vitp 2003 LT EA RN D SION RTNIENT USE ONL ♦ Application.Accepted By Date 6} Area Employee ID= +'�" �f'CJYYY"VVV Date 13 SPECIAL Well Permit Grcut Inspection By Pump Inspection By Date ❑ WAIVER Received Destruction Ins ection By Date Constructed Well De0b ft C0NLti NTS PE SC Amon Chegll. Receiv-ed Date Permit/ Invoice# Well ID# Codes Info Remitted Cash B Service Re uest# - Mastcr Watcr Well Pcrmit.dm EHD 43-02-006 2/14!2003 �1