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WELL/PUMP PERMIT • SAN JOAQUIN COUNTY E-HtoN>IE. ALTH DEPARTMENT 304�.WEBER*ES $l OCKTON CA 95202-(209)i68-3J20 NON-REFUNDABLE PERMITC):11:1.(209 933-7697 FoR INsn,(710N$ I YEAR FRom DATE ISSUED N - rl/)tb l l T. B t• F. • JOB ADDRESS F Ta 1�F4R4 Waycrl�Rrl Crrv2lPlFinr7cn r �.�� > j� r� C CROSS STREET lood Rc)Hd APN PARCEL SIZE .Dm OWNERNASIE rmi n PHONE 209-468-3066 o u l c W r S CITY/STATE/ZIP stockton CA 95201 OWNER ADDRESS CONTRACTOR Martell Water Systems. Inc- PxoNE(92��4��-4� CONTRACTOR ADDRESS 1818 Loveridge Road CTTY/$TATEIZIP Pittsburg,CA 94565 SUBCONTRACTOR N/A PHONE SUBCONTRACTOR ADDRESS CRY/STATEMP LICENSE X C-57 :6 C-61 ❑D-09 ❑Other NUMBER 510952 EXPIRATION DATE 5-33-05 GEOGRAPHICALINFORMATION: Coordinates X Y Township_ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial [Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System ontautNa—or Phone Number If different from Owner '.-Jy.nem .- TYPE OF WORK 13 New Well ❑Replacement Well ❑Well Alteration/Modification XTest Hole ❑Other number otM,dn,. ❑Monitoring Well(s) numberof—IN p Soil Boring(s) num ofbuengs p Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Re it ❑Cross-Connection Re air WELL CONSTRUCTION ❑Other yyyyy Drilling Method ❑Mud Rotary Air Rotary ❑Auger ❑Cable Tool 0 Push Point Proposed Well Depth ft Excavation J!5 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size m diameter F•-t ❑Conductor Casing in diameter / Conductor Casing Depth ft Nell Casing Diameter in ThicknessiGauge+ASTM Sched _ ❑Steel ❑Plastic ❑Stainlers Steel ❑Other _ Grout Seal Depth ft Neat Cement(941b htg 5-10gal water) ❑Sand Cement sack mix!7 gal water El Bentonite(20a/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ft Length ft Thick in ❑Christy Bos ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth k Depth to Water ft ❑Casing to be Perforated from R to ft Sealing Material 0 Neat Cement(9116 bag 5-10 gal water) ❑Sand Cement sack mit/7 gal water O Bentonite Pellets ❑Bentonite(20a/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ko ❑Complete with Mushroom Cap ft below grads ❑Complete to Existing Surface Pad In IIQ 1 HEREBY CERTIFY THAT 1 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 MY REQUIRED LICENSE IS Ol �� CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE NYITH ALL / NN'ORKERS COMPENSATION LANN'S. _ " �Il �l 2 R ALIN ANCE NO'IY('I:! (1l'IREIJ)1 O1:iNtiPl:('"1 IONS SIGNED - TITLE �f/4B I DATE -v go l DEPARTMENT USE ONLY Application Accepted By / Date Area Employee IDs Grout Inspection By r [(R,S/�J DaSe ❑ SPECIAL Well Permit i Date ❑ WAIVER Receive Pump Inspection By Destruction Inspection By Date !i' �3 Constructed Well Depth ft COMLNIENTS PE SC Amount Check#/ Received Date Permid Invoice# Well[DO Codes Info Remitted Cash B Service Re uest# Master Water Well Pcrmitdoe EHD 43-02.006 2/14,'2003 -