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I i WELL / PUMP PERMIT SAN JOAQUIN COUNTY EN VIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT .I�. "'"CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED Z' JOB ADDRESS a Lam a VY - rive — CITYIZIP 1 iye je - _ 9 / !r,_ v CROSS STREET ��f ✓fir�I� APN �`f'io-I`�©rl. PARCEL SIZE '2+��LAND USE APPLICATION# X ! OWNER NAME IVfG1C Y(� _J W! C1�G �IL6fJ(Z�6�I , PHONE OWNER ADDRESS /L1 2!gsIp(few�rdQCITY/STATE/ZIP o CONTRACTOR. leon Id"i •�t) C— - PHONE 1 CONTRACTOR ADDRESS . .17- MVr St _ CITYISTATEZIP c� as s +� iS7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS I� CITY/STATE/ZIP t 2 LICENSE- IXC-57 ❑C-6l ❑D-09 ❑Other ..-• +,-rI* NUMBER y6 7A 5� EXPIRATION DATE �Z 7 1 i GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section 11 INTENDED USE ❑Domestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring PWSoil Sampling/Characterization - ❑Public Water System If different from Owner: Water System ame omact e e TYPE OF WORK ❑New Well fk❑Replacement Well CI Well Alteration/Modification borin❑"F oe Oth I ! ❑Monitoring Well(s) #of wells ❑Soil Borings} I of JV Geotechnical tk of borings ❑Well Destruction+n+[�[rr ❑Out-Of-Service Well PLQt iiS l-,tyWH1'S��nev P"ffl ��bo}ut " ❑New Pum Af❑Pump Replacement ❑Pump Re airy ❑Cros o t vn inrB±✓tE[� WELL CONSTRUCTION p�m ` y, n Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool � Sb-Wil0rt�Otht1 Heaftl I Dj�' �d� I u of Proposed Welk Depth 6':l Q R Excavation, , in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing m diameter 1 Conductor Casing Depth ft Well Casing Diameter inThickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other :Grout Seal Depth !I. ft ❑Neat Cement(941h bag/5-10 gal water) ❑Sand Cement .rack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name e ! , 'Specs on File ❑Specs Submitted 2 Grout Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) {^ PEDESTAL Installed By I� ❑Driller [3 Pump Contractor ❑Other ") ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible I� ❑Turbine ❑Other -HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other e 1M n Tot ept Depth ❑ e P ora es g Material ❑N C 941 15 gal w r) ❑Sa Cement ck m 7 gal er entonit ell E. 0%,� i an cturer %solids .me a bmi d Place nt Method ❑ ed ❑ ee l ❑Other mplete w hro Ca below grade ❑ to to Existin urf Pad Ik 1 HEREBY CERTIFY THAT l HAVE PREPARED THIS 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ► MINI M 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 1 (j r TITLE DATE SIGNED i f A404K— IF pMalfe- 4 Iw NT IM : uF! DEPARTMENT,US ONL y S �/1/`' / Application Accepted By if Date z Area �� Employee ID#�_ �/ Grout Inspection By �`I. Date ., ❑ SPECIAL Well Permit Pump Inspection By I�I Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS I� PE SC Received C eck#/ Amount Permit! I Codes Info 8 s Remitted Date Service Request# Invoice# Well Ill 43.7 7- t S'0Z 77 tap l 31,73� b i EHD 43-02-006 MASTER WATER WELL PERMIT 12/22/2003 ` II a.