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I WELL 1 PUMP PERMIT ' ! SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 1 WEBER AVE 3"6 FL-STOCKTON CA 95202 - (209)468-3420 'NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Sim Crl7�� JOB ADDRESS � 4 LFA � CITYIZIP / C !! "S�— tz CROSS STREET APN r 3� D-!f 7CJL 9, I. PARCEL SIZE LAND USE APPLICATION# X OWNER NAME Jl./1�t 0 .L L/l &A 5 _ PHONE OWNER ADDRESS ,q ��Cr4&ke� cr CITYISTATE/ZIP �b / `�/ � G G CONTRACTOR C..t/1+C� r 1 I � o0i yr PHONE—3 3 ¢0 CONTRACTOR ADDRESS & -�, ( i SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP l LICENSE C-57 11C-61 ❑D-09 13Other NUMBER (/D EXPIRATION DATE i GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section ' INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring Soil Sampling/Characterization i ❑Public Water System If different fromowner: ater ystem ame " act Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modificati n _- i-1e t _ th #of borings .. ofborings ❑Monitoring Well(s) #of wells oll Boring(s)� F� �p�} t-t•�� y, ❑Geotechnical ❑Well Destruction C]Out-Of-Service Well Perfa 4ut�(7t y,eAaleleKpifd Without ❑New PumR ❑Pump Replacement ❑Pump Repair 'WQ I WELL CONSTRUCTION 4 h '_ Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Uy E d.bl&fll o L ial#h r t' cm d IJ Proposed Well Depth_ft Excavation l0 t t in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size to diameter ❑Conductor Casing in diameter /. Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sehed ❑Steel ❑Plastic ❑Stainless Steel ❑Other I Grout Seal Depth ft . ❑Neat Cement(94 lb hag 15-10 gal water) ❑�Sand Cement ,tack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 5O11- ccm ❑Specs on Fite ❑Specs Submitted I Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name` PEDESTAL Installed BY ❑Driller ❑Pump Contractor ❑Other' ',i ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PIIMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Levet 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 Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%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 1 HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ' NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE DATEr–2 4 1, 'L� _ ixs �q r� '�, �a-i of r��' ,� � �✓."- `�- � � - tt � 6 26 vt t Ca Y3 E S �;DEPARTMENT USFONLY T .. Application Accepted B Date Area Employee ID# Grout Inspection By Date 4 0 SPECIAL Well Permit Pump Inspection By Date © WAIVER Received Destruction Inspection By Date Constructed Well Depth ft / 14 ,} COMMENTS f'�r7 ( � r` — PE SC Received Xheck#t Amount DatePermitl Invoice# Well ID# Codes Info Remitted Service''Re uest# 1 `7' PQ EHD 43-02-006 MASTER WATER WELL PERMIT 12/22/2003