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0 0 z-D WELL/PUMP PERMIT SAN JOAJViN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE3-FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)9S3-7697;PR INSPECTIONS EXPIRES I YEAR PROM DATE ISSUED N m roe ADpagss CRVIZIe TRgGL, 95.49/ > CROSS 51'RELT ^ APN 20 /;��-�/I7 ,A-QL ' NP.ARCEL$IZEZS�LAND USE APPLICATIONp °e OWNERNAME _TtMp ZV MTIE< PHONE 249 836-/560 OWNERADDBESS .3/20 TFACIA /3LUAI Sl[!-/'E/j CITY/STATE/ZIP�s LA_ 91537-/ CONTRACTOR E t TNM TN r+P.IK f IA1C. 1+ `PxOne Ilia`LY'�/bJ C$/� CONTMCTOR ADDRESS /917 Fiai1NK WEST C ZC. 1 ten IM 1 CRY/BTATE/ZIP ]T ✓TUAI/1-14 '952 SUBCONTRACTOR SP6.L-rdJm )5y/3TARdTpA7 PHONE 71/9.445-83/7 . `fly SUBCONTAACORADDRESs 236S W/C41J1M /K• CITY/STATFAZR �Zlq`L7A195z05 _ v LICENSE C-57 0C-61 [3 D-09 [I Other NUMBER 51224re EXPIRATIONDATE n GEOGRAPHIGLINFORMATIONI Conrdlxahr % Y Township 2 S Rangel�t._ Section C\ INTENDED USE ❑DOmatieTTv 1r, ❑Imgalion/Agricultutal ❑Industrial Water Quality Monitoring O Soil serpimeclurveknmliore O Public Water Sy3rem HelHertmhos0u'Inr: ekr nu- eme Comss N.me car 11c.Madan TYPEOF WORK ;KBw Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ;B(Monimdng Well(s)_LN.f wells ❑Soil Bodng(e) rend"m OGcO[ahnicel nOrbon.® ❑WeII Deetmclion I13 ❑Osw-0f--Service Well 13 Out-Of-Service Well Renewal O New Pum ❑Pum R acemrn ❑Pump Repair ❑Cmcas Connection Repair WELLCONSTRUCT10N Drilling Method ❑Mud Rotary 13 Air Emery ,Auger ❑Cable Tool 13 Push Point E3 Other Proposed Well Depth 25/ 0 Exavmion in diameter ❑Open Bottom El Gravel Pack/Gravel Siuin diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter 2 in TbicknmVGauge/ASTM Schad40 ❑8sal �PlRrtic 0Stamlem St.] ❑Other Grnut Seal Depth A'-//T ft XNat Cement(➢4lDhag/5-/Ogolwater) 17 Saudi Cement .mak m¢/7 gal eater ❑Bereonite(20%solids) ❑Manufacturer Spec%solids_%. Name ❑Spas..File ❑Speca Submitted Grunt Placement Method ❑PumpM Fra Fell ❑Other ❑Reterdanl/Amelerator(mme) PEDEBUL Installed By '@(Duller ❑Pump Contractor 13 Other Concrete Pedetlal Dlmenaima: Width-y5 ft Length-5-fl Thick T/ 1. ❑Christy Ross Stove Pipe Pump ❑Submersible ❑Turbine OODIef HP Pump Set R Standing Water Level ft WELL DESTRUCTION Cl Open POLISH O Gravel Pack 0 UneBsed ❑Other Well Diameter in Total Depth R DepN to Water ft O Casing to be perforated from_R to_A Sealing Matertai ❑Nat Cement(94 Ib bag15-I0gal water) 0Sued Cement sockmix/7gal Water OBrntonite Pellets ❑Be.umit,RVI.solids) ❑Manufacturer Spa%solids_% Name ❑Sperson File OSpem Submind Placement Method ❑Pumped E3 PER,Fell ❑Other ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Ped 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACFF"tV& H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIPORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN CQf)P�I9f'C4 n5l ALL WORKERS COMPENSATION LAWS. �{{�(ff 11 J.LL000U44 MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SAN JOAOUIN GOU slcrve t�ATMAT T.!L aAMG66LUGl5� DI gENVO �L it P` >2L'g-/''e•�, 9h°`-1- Mjj PARTMENT ON Y C -- Ntra w.;•; Application Accepter Date AraqZk Employee im IYJb Groot Inspati, By Date ❑ SPECIAL Well Permit Pump lnspertio y Date ❑ WAIVER Received Destruction Ivpation By Date Constructed Well Depth It COMMENT$ W -11/L E SC R«elver h Amount Date Per-onto Code, Well lDq Codes Info B Cash Remitted ServlceR uestg EMuEH3 OOfi 041, hip �1D9-U7af'I Y 4MASTE0.WATE0.WELL PERMIT