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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL,H£ALTN DEPARTMENT - 304E 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 y JOBADDRESS 173 S 3L t ► fZ„VM �., CITY/ZIP— CROSS r y ( CITY/ZIP a ` 0 CROSS STREET I�E,n/AL�}'(y(/ �fQJ� ppN Z09-J6Q -I2 PARCELSIZE-Md1A<LAND USE APPLICATION It p N OWNER NAME Ip/M Ailw e!fn' XIWI JAlI TI9�; PHONE 17rJ�J_ f36_��60 `•' OWNERADDRESS 3 1ZO �7TAAT d-u'b �LLITF A. •�+ R CITY/STATE/ZIP 1 LJl� CONTRACTOR / udp 2', -Q =Xe y2AMZ CI&165 I A16 PHONE 2&1.2�-6 1 CONTRACTOR ADDRESS /�FJ24AJ.k �lIZST CiPL1 frlrTl7//�G CITY/STATE/ZIP ^fj I^7J7,4JJ '4 9: /1/ SUBCONTRACTOR 5- ryLLe-`)EVM �XPLI09 77W PHONE ( ,Y SUBCONTRACTOR ADDRESS�'41S 1 /� -��,/1^ Z))7 CITY/STATE/ZIP '�'7-QL/["JD�(/l�/t 9'C�S V_�' LICENSE C-57 -0C-61 13 D-09 11 Other NUMBER EXPIRATION DATE C2 ilz3—o/0 GEOGRAPHICAL INFORMATION: Coordinates X Y Township2---5 Range 4C' Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial (Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Udifferenl from wnec emr yssem eme onlnct eme ar one um er TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hale ❑Other IXMonitoring Well(s)--j—#ofwells ❑Soil Boring(s) - #ofborings ❑Geotechnical #ofbodngs Nm_ ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Re air ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary keAugCr ❑Cable Tool ❑Push Point ❑Other . Proposed Well Depth ^-J_6) ft Excavation in diameter ❑Open Bottom O Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft - Well Casing Diameter -Z±1 in Thickness/Gauge/ASTM Schad �O ❑.Steel astic ❑Stainless Steel ❑Other Grout Seal Depth n -)I f Real Cement(94 lb bag/5-10 gal water) ❑Sand Cement - sack mix/7 gal water .rv. El Bentonite(20%solids) /❑`Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted ' v Grout Placement Method ❑Pumped XFree Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By *riller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Widlhe✓< ft Length ..ter ft Thick 1/ in ❑Christy Box Love Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water fl ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids)- ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. - INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ,L>' —F&#, TITLE :-r,4 FFCj O A 1<7' DATE -------------- --------------- ------------------ --------------- 4 4Z . - DEPARTMENT USE O LY Application Accepted By Date AreaEmployee IDN / r Grout Inspection By Date �❑SPEYYCCIAALL Well Permit J� Pump Inspection By Date ❑- WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS040(12y '➢�a1 n� In �t'(f1/x1r atlr Ii Afl/.(�, �(Yz rl�I�(/—> t� �Cr1JT/+•+x.1!¢ r PESC Received Checldl Amount Date PermiU .Invoice# WeI11D# Codes Info B ash Remitted ServlceI oast# /I EHD 93,02-006 12/2]/3003 ' MASTER WATER WELL PERMIT