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WELL P' --.f PERMIT 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3N"FL-STOCKTON CA 95202 -( -3420 NON-REFUNDABLE PERMIT CALL.(209)9$( . .r FOR INSPECTIONS EXPIRES 1 YEAR FROM DATERD JOBADDRESS VCJ�gV --.:I CC)sell Z1aLLLY-✓ rel„ CITY/ZIP /rG r�C-t�i 1.r `�' ✓ m f� O CROSS STREET XJ APN 2 S"-- O -3 /b PARCEL SI"!.E_ 60 m p OWNER NAME Ci OuUrU UFr�p/J `�UL 4EJ {��L�T-It,7�- ' /v«kLlI C. h/C)'Z a PHONE - S/6 4'�-30 6.6 OWNER ADDRESS l'J�•�y�[-- �'CJyT2"- Cr7I/E-,1VUF' / , CITY/STATE/ZIP CONTRACTOR /1/plLi�✓��/(C. `wley�- J�IS .JAL ,P^IHONE �- I�+�Cr CONTRACTOR ADDRESS /C3/C� `0(IVG./1sQ(,e 0-11- CITY/STATE/ZIP ' 7� aq,z4� l.a SUBCONTRACTOR /V��- PHONE /4 SUBCONTRACTOR ADDRESS /L « CITY/STATE/ZIP •N�� V� � s LICENSE. NIC'-57 E C-61 ❑D-09 ❑Other NUMBER �� C l EXIT RATION DATE - �-d_,S GEOGRAPBICAL'INFORMAPION: Coordinates X Y Township_ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial &Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IfdiDerent from Owner: Water System Name Contact Name or Phone Number TYPE Or WORK ❑New Weil ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other -� numberofwells ❑Soil Boring(s) numberofborings ❑Geotechnical numberofborings E ell Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION / Drilling Method ❑Mud Rotary L7irti a ❑Auger ❑Cable Tool ❑Push tom❑Other rt Proposed Well Depth 4,,� It Excavation in diameter ottom 92<ravel Pack/Gravel Size Ai 2.. in diameter ❑Conductor Casing in diameter / Condue epth ft Well Casing Diameter in Thickncss/C; ge ASTM @Mastic ❑Stainless Steel ❑Other Grout Seal Depth •Z ft ❑ ement(94 lb hug/5-10 gal water) an eDt_` -// _sack this/7 gal water ❑Bentonite(20% ❑Manufacturer Spec%solids % Name �7S ccs on File 19'Specs Submitted Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) -L✓ PEDESTAL ,,n,,s,Ca�e Pum Contractor e /N tuweaerctc'Pe2feestal idth R Length Christy Box fid'Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level Ii WELL.DESTRUCTION ❑Open Bottom Gravel Pack „ ❑Uncased ❑Other 3(;!,Well Diameter_'in Total Depth 267t;? 'IA ( Depth to Water Il ❑Casing to be Perlbrated from It to ti Sealing Material ❑Neat Cement(94 lb hag/5-10 got water) hand Cement----J sack mir/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted l Placement Method 9,Pumped ❑Free Fall - ❑Other ❑Complete with Mushroom Cap H 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 H DV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-17697 SIGNED ' ' TITLE /J2 N1 �li DATF. i is B'wune wEu nwd � � y •BAN00-10 rntt. PER sec-rad] 1 Jr� vinv 1', 6 PB�NOON WELL t �-�, 4CNrtpV!Nc'Pal iwSrkUnON PBBIE� T x L-La vNinn teucru `mB wE,t wnv-t(FlB"al eBa oN� +Fu "\ DEPARTMENT U'E O LY �r\. -�1 cl_a a L7 Employee)D# Application Accepted By Date 722 u; Area Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspecti y_ Date ❑ WAIVER Received - Destluctidn Insppectitio/ 7 Date 0 Constructed Well Depth ft _EOMMENT3� )-;i PE SC Received Check#/ Amount Permit/ Codes Info By as Remitted Date Service Request# voice# Well ID# Ir - F5 11)43-02-00(>•' .•I'�'�L?'' �' �/zor- d/'��/j>.ra c ; ��1•t /moi/ �'x>�.� ��t�5 W :( ..1.PERMIT