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WELL OMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"a FL-STOCKTON CA 95202 )468-3420 - NON-R. UNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �^t2-y�7 rn JOBADDRESS 23 C1 �- �✓ 'L 1Z Ot-LI-- /2/ CIT7Y/ZIP7� -� 1^ /G/� ( y CROSS STREET --------'F l APN _?C)1 C7 PARCEL SIZE '.AV• ' ® A zs-��- OWNER NAME C.CC.t/T//? CJS .-.]/'.J 76114L/�r/0- IJ!-�/, L7F /-/11y�L(C L'�CY„y(S PHONE t_2L'rj 4(619,^ 3 C16 6 OWNER ADDRESS C�)JC-.� C- �I/�I/LL �-7✓l% CITY/STATE/"LIP .<7—MC-1C-rrV, l A7�1 -(/(201 CONTRACTOR /��J/.0/T�1�.�� 1fli C- PPHONE__ CONTRACTOR ADDRESS /6/6 (7 /'�(/6 LO ve/�//JC, '! CtrY/SFArt:/ZIP / 2/TA4;< 0ZL,,C-14 Cl V f6 K . SUBCONTRACTOR 4z4 „��11 PHONt: SUBCONTRACTOR ADDRESS ✓ A'4CITY/STATE/ZIP LICENSE CYC-57 19 C-61 ❑D-09 O Other NUMBER AN j..a EXPIRATION DATE ✓ .�� (},S VoV GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section (� 777 ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization❑Public Water SystemI(mNerent from Owner. Water System Nam Contact Name or one Number TYPE OF WORK �❑,,N ❑Replacement Well [3 Well Alteration/Modification ❑Test Hole 13 Other L5'Mot7itoring Well(s) numberofwells 0Soil Boring(s) numberofborings 0Geotechnical ornber.borings 74711-thstwetien ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Re lac ent ❑Pum Re air ❑Cross-Connection Repair WELL CONSTRUCTION c � Drilling Method C)Mud Rotary CiYAir Rotary ❑Auger ❑Cable To� ❑Push Point ❑Other Proposed Well Depth/ tt Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size_j in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R © a Well Casing Diameter�in Thickness/Gaugc/ASTM Sched -<Ck4 4 0 ❑Steel GKPlastic ❑Stainless Steel ❑Other Grout Seal Depth ft ” ❑Neat Cement(94 16 hag/S-10 gal water) 1!1 Sand Cement I S:-+0C- suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method OI•Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other O Concrete Pedestal Dimensions: Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft ((( WELL DESTRU ❑Open Bottomravel Pack ❑Uncased ❑Other Well Diameter Total Depth fl Depth to Water ft o e Perforated from fl to ft Sealing Material ❑Neat Cement(94 lb m1 water) ❑Sand Cem sack mix/7 gal water- ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufactu ids % Name ❑Specs on File ❑Specs Submitted Placement Method 151fumped 0 •all ❑Other ❑Complete with p4estf"room--C'ap B below grade to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE D IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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. MINIMUM 4yd0URA16GNCE NOTICE REQUIRED FOR INSPECTIIO}.�NSS-PLEASE CALL(209)953-7697 SIGNED TITLE S3C.C� /z /"'/�-� `� DATE / 1 LucidE WLL 4aNaw1 YW nnr PMuses LLMYI< +pft ae•1 <oxno»Mr� � w VER 9ECTON tOdt� 1 6 B ®, . .'� tet' t,`, ;•i PF0.9E�elION '��—w.. I/ / tlONIIeNINa NEIL PTIIUMW Iad[ci 7"w< rlanx z Ca llo `INSTALL WELL Mw.r IFlOURE a aROeN—Messaca,"HELL EOGneN w0 ARTMENT/USE ONLY Application Accepted By lAM1 ,`4W WW CO�tr"'°""°"" J Date I -JS-o 3 Area a i V Employee ID#_LLI56 Grout Inspection By �.7�7i�x, 01-11>&q Dat !;3 3 ❑ SPECIAL Well Permit ��// Pump Inspection By Date ❑ WAIVER Received R Destruction Inspection By Date �f Constructed Well Pepth ft .0 PE SC Received eck#/ Amount Date Permit/ �' # Wei11D#� Codes Info By Remitted Service Request# S Sz 99 ISO 1800 3 33 EHD 43-02-006 MASTER WA 11 R WFL1.PERMIT