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WELL / PUMP PERMIT 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . 304E WEBER AVE 3s"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT , l CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS /t/ 1,y em'II CITY /ZIP�J�q5AT91 CROSSSTREET 6950CROAD AIN &1-6:3 -6j PARCEL SIZE SHtSr ymO /^ ISAraND USE APPLICATION# p OWNER NAME r..�/2/YNtl PV 4.0/11MNi(91''71L+S - - PHONE ?12-836'/SGO: y T k: OWNERADDRESS �J+/�ZDT�ILy SurrkA - CITY/STATE/ZIP �7P.IgGyfCa 95-J7G y CONTRACTOR AIOb rCd41'1T'r �i>l�rrJ//aiFSI /All PPHHONNE�/��l�$/'_ CONTRACTOR ADDRESS /ST r7ZAA)/C 1.1657-(,�/ !L-6 L_r T.� - CITY/STATE/ZIP /vt c.7�A// 4 /4 2:524011� SUBCONTRACTOR GTyr / / PHONE 2-01-Y45- 8717. SUBCONTRACTOR ADDRESS 2-3(0,; f-✓/[y W/'�IY11� CITY/STATE//ZIP 5*1-04-470A..O d /5205 \ LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 512 Z(e p EXPIRATION DATE 4P 36 Q GEOGRAPHICAL INFORMATION: Coordinates X Y Township11 .Range �f Section 33 /- INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial Water Quality Monitoring ❑Soil Sampling/Chamcterization ❑Public Water System - - if di Rerent from Owner elm yslem ame pnract eme or one um er ' TYPE OF WORK YNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole. 13OtherrN - Q fborinr - XMonilorin8 Well s---v- #of wells ❑Soil Boring(s) Nos 11 Geotechnical N ofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION - ��s,,,.../// Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 1 Z/+25' ft Excavation I in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter O Conductor Casing - in diameter / Conductor Casing Depth . ft /I -� Well Casing Diameter 2.7 in Thickness/Gauge/ASTM Sched 416 ❑Steel Aplassic ❑Stainless Steel ❑Other Grout Seal Depth -v,ft -Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement ,rack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped rce Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By XDriller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width-L- � R Length!t. ft Thick in ❑Christy Box Love Pipe PUMP '❑Submersible ❑Turbine ❑Other IHP Pump Set ft Standing Water Level 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 1b bag/J-10 gal water) ❑Sand Cement - sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on 5V ❑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. 1 ALSO CERTIFY THAT MY REQUIRED LI SE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE pq L WORKERS COMPENSATION LAWS. 'T INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CF/(��/r SIGNED ,e: CWAD01i TE . TITLE 7AfF C--6OZ0615T DATE P a. i DEPARTMENT IFE NL Application Accepted By Date- Area Employee ID# Grout Inspection By - Date - ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection Byy / Date Constructed Well Depth It COMMENTS � d! rl hA IGS/ iQ Pit/T7/' <� Vpj2b,, �cN63 ✓ys F'�---/I- ^"rA Mtl/ PE SC Received ec - . Amount Permit/ / Codes Info By A sh Remitted ate Service Re uest# Invoice# Well IDN / 2S /1 3`i ) EMD 4342-OOH MASTER WATER WELL PERMIT 12R2/20W