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WELL/PUMP PERMIT • SAN JOAQUIN COUNTY ENVIRONNEALTH DEPARTMENT 304 E WEBERA L-STOCKTON CA 95202-(209)46&3420 NON-REFUNDABLE PER}IIT L-AII.(209 953-7697 FOR INSPE("1'IONti ES 1 YEAR FRONT DATE ISSUED rn rvN�hi 1 l T. • JOB ADDRESS F anc]fi l l 6484 Wa erL Rd— CITY21PLiTII�C �.�,�� c �t CROSS STREET C rl,(X)d Road APN PARCELSIZE ?° OWNERNANIE inpriuln Caun y of SanPHONE 209-468-3066 oPublic W r S CITY/STATE/ZIP Stockton CA 95201 OWNER ADDRESS CONTRACTOR m ;:-11 :•:a}pr c-r��E'�Sy TnC PHONE�2)432-47� CONTRACTOR ADDRESS. 1818 Loveridge Road CITY/STATE/ZIP PittSburg,CA 94565 SUBCONTRACTOR N/A PHONE SUBCONTRACTOR ADDRESS CRY/STATE/ZIP LICENSE XC•s7 'S C 61 ❑D-09 ❑Other NUMBER 510952 EXPIRATION DATE 5-31-05 GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section INTENDED USE 13Domestic/Private ElIrrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System ontact me or um r If different from Owner: W.-System ume I&V TWE OF WORKrwilVell eplacement Well ❑Well Alteration/hfodification ❑Test Hole ❑Other numher ofM,rinps beruiwells p Soil Borin s °umhrofb,mnps ❑Geotechnical ng Well(s) Boring(s) ❑Well Destruction �g ❑Ou[-Of-Service Well ❑Out-Of•Service Well Renewal ❑New Pum2 ❑Pump Replacement ❑Pump Re air ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary )(Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing NI in diameter / Conductor Casing Depth ft Well Casing Diameter_,2.,_in ThicknessiGaugetASTNt Sched ❑Steel Kplastic ❑Stainless Steel ❑Other Grout Seal Depth C It Neat Cement(94 lb bay'5-/Ogal[rater) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Nlethod Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) PEDESTAL Installed By KDriller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_It Len_eth ft Thick in ❑Christy Boz love Pipe PUNIP ❑Submersible ❑Turbine ❑Other HP Pump Set 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 It to ft Sealing Nlaterial ❑Neat Cement(9J/b bay 5-/0 gal water) ❑Sand Cement sack mit/7 gal water ❑Bentonite Pellets ❑Bentonite(200ro solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION' AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN W JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT NIY REQUIRED LICENSE IS Cl-) CURRENT AND ACTIVE YY'ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 ANI IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. N NI\Il NI 2Oelm'1t ADN.ANCE NO'l 1('I IZ 'Ql'IIZF.t FOR IN'SPEC'TIONS C SIGNED TITLE ��S I Y ✓ e DATE 0 a IL M———————————— —————————— --------------- ------------ --------------- --------------- ------------ DEPARTMENT USE ONLY Application pled By Date Area Employee IDH Gr t Inspection Dote G /o D - ❑ SPECIAL Well Permit '`' •^� Pu Inspect - ''S ❑ WAIVER Received — Destruction Inspection By /Date !e,-04�� Constructed Well Depth ft CO%LNIENTS PE SC Amount Check#/ Received Date Permit/ Invoice Well IDH e Codes Info Remitted Cash By ServicRe uest H Master Water Well Permitdcc EHD 43-02-006 2/14/_'003