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•»� WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D TM ENT 304 E WEBERWO FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn H JOB ADDRESS CITY/ZIP -72ACy, 95391 H a," o CROSS STREET ..NyE,IbE�.S u/ROAD. APN 2l)9^030^d', PARCEL SILE 595,/SALAND USE APPLICATION# A OWNERNAME r IJ"ARY 6MMhr1j)`TI&S F, PHONE 709-966-/51.0 ..., OWNER ADDRESS .31� &Vh, ,SU/TL-A CITY/STATE/ZIP -7LA�-yICA 9S•/37G CONTRACTOR C-�NOO/Lrr'�✓<A!L'TFI1. 'TEGJINOl1�' lE-S I /A)e 7- ,��PHONN-E�u/ -Z13�T 'pO '^�,_ CONTRACTOR ADDRESS /SSe f�77^m< UIESTG.t'GL/z I'Su/TEL CITY/STATE/ZIP JTr+(��A1, ('..4 /S2.Vr, SUBCONTRACTOR SPf-G-rJ um -XiALaim-roAJ - PHONE-Z0'1-1145- 8 71Z- SUBCONTRACTOR ADDRESS 23(nrj W/GW/'}N1 /)JZ . CITY/STATE/ZIP 570 To.V/e7 4 `75ZOS LICENSEC-57 ❑C-61 ElD-09 ❑Other NUMBER-51Z U, EXPIRATION DATE .30 d /1 /E 7 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sampling/Characterization ^� ❑Public Water System Ifdifferent from Owner Water System Name Correct Name of Fhor,,Number TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hale. ❑Other g () p Nof boring Nof borings �Monitorin Well s—t,J—#of wells ❑Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service'Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION www,,,/// Drilling Method 13 Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /Z 1+25/ ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing - in diameter / Conductor Casing Depth ft + Well Casing Diameter Z in Thickness/Gauge/ASTM Sched ❑Steel Plastic ❑Stainless Steel ❑Other I Grout Seal Depth ^// ft ,KNeat Cement(94/b bag/5-I0gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ree Fall ❑Other ❑Retardant/Accelerator(name) - +. PEDESTAL Installed By Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width ft Lengths. ft Thick � in ❑Christy Box 55,7tove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft WELLDESTRUCTION ❑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 lb bag/S-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on Fg., ❑Specs Submitted . Placement Method ❑Pumped ❑Free Fall 13 Other f ❑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. I ALSO CERTIFY THAT MY REQUIRED LI SE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE L WORKERS COMPENSATION AWS.;NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ryU Oel SIGNED : CouDOR I TE . TITLE 7AFF 06OL061ST DATE 1I Ad I I I I I I ;r Q P '. DEPARTMENT SJ.SE pNLy r/ Application Accepted By �+ Date //L///-,/OIL4 Area Employee ID# (LJ Grout Inspection By Date - ❑ SPECIAL Well Permit /7 Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ff // x A - �4'l f waste COMMENTS h411 Yrl/IYI (j ( IQ�C PJ� JA-t!o._VQLL ( e1tEF-� 6 MW I �a�S� uwt��r PE SC Received ec Amount ate /r _Permit/ Invoice# Well ID# Codes Info BYA Sh Remitted f Service Request# no Z)9 IT I EHD 43.02.006 MASTER WATER WELL PERMIT 1=00a