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LL / PUMP PERMIT i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT - CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED I � f�3s3 w•rg E�Tq'N JOB ADDRESS �Ic fA/.I�aC SOH K-O• CITY/ZIP MTA L\/T n I-�SF m D q v CROSS STREET L7J?i ! APN Girl ' 160- 1Z PARCELSIZE y`Q-r N LAND USE APPLICATION# A N OWNER NAME =0 iJ✓eGl Y. (" � � rs s'u- '1't't"L�� SC y� PHONE OWNER ADDRESS 3t'�/1^�4� ' y� ' Ci • l SE414 4-1 CITY(STATE/ZIP Tre;t_yy Car '55 3�r p-3 e, CONTRACTOR l ,7 J.Q/�O✓ FL✓ TIfNIA 0 � PHONE1/L.1L�'I' L�'ry'�Ip CONTRACTOR ADDRESS U ^1.,,+ti e I �e�-J sk CITY/STATE/ZIP �'OCI[--7{-lN SUBCONTRACTOR _Tfe .'I^ / � X�.`� I.� I� lA C PHONE < 0"t - t-�I� G - g� SUBCONTRACTOR ADDRESS [,. 61 W I Fj LA) I✓(IYG-. CITY/STATE/ZIP UC KAwk LICENSE p(C-57 ❑C-61 ❑D-09 ❑Other NUMBER 617765? EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range:: Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sarnpling/Characten-hon ❑Public Water System _ If different from owner Water System Nero, ontect eme or one umer TYPE OF WORK XNew Well ❑Replac ent W II ❑Well Alteration/Modification ❑Test Hole ❑Other it of burin s Monitoring Weil(s) el ❑Soil Boring(s) a ❑Geotechnical a of borings ❑Well Destruction ( ' ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑New Pump ❑Pump Re ce t ❑Pump Repair ❑Cross-Connection.Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary 0 Air Rotary KAuger ❑Cable Tool ❑Push Point O Other ! Proposed Well Depth 25 ft Excavation (2 diameter ❑.Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth • ft W Well Casing Diameter in Thickness/Gauge/ASTM Sched ;HO ❑Steel Plastic ❑Stainless Steel ❑Other N Grout Seal Depth_r ft WNe.t Cement(94 Ib bag/5-/0 gal.water) ❑Sand Cement sack mix/7 gal water 1N ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs.on File ❑Specs Submitted Grout Placement Method ❑Pumped Free Fell ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By )(Driller ❑Pump Contractor ❑Other _ O Concrete Pedestal Dimensions: Width_ ft Length_R .Thick in ❑Christy Box (Stove Pipe . PUMP ❑Submersible ❑Turbine ❑Other - HP Pump Set ft Standing Water Level' ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased LJ Other '`Y1 Well Diameter in Total Depth fl Depth to Water ft [I Casing to be Perforated from ft to. ft $ Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal water) O Sand Cement sack mix/7 gal water ❑Bentonite Pellets Z O Bentonite(20%solids) 0 Manufacturer Spec 00/solids_%- Name : ❑Specs on File ❑SpecsSrubmit[cd Placement Method ❑Pumped ❑Free Fall - ❑Other ❑Complete with Mushroom Cap it below grade - ❑Complete to Existing Surface Pad l7 I 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 ACSO�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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE D DATE \ ro v 77 { e•s JJ� w .pv t H zril 1, fp , fs NOATN ss .t' ro It rIT' IT- 5�9 /� DEPARTMENT USE M1LY ' Application Accepted By. LLL Rate S f S U '-ca Employee ID,I 1{Obt� � .. Grout Inspection By Date _ ❑, SPECIAL Well Per[Ilit Pum Inspection By Dale P P ❑ W,UAER Received' Destruction Inspection By Date - Corot rut ted\V ell Depth it COMMENTS —EZZr l�h 0 r F�C�FN/ F� PE Coded SC Received Check#/ Amount Dale Permit/ Invoice# Well IDd . info B as Remitted Service ReQuest P r3: :s fsz' �� 9 asro.Dc, Esc S✓�oais EHD41-03-0a6 MASTER WATER WELL PERMIT