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(. .� VELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DOME304 E WEBER 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 F R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS r — CITY/ZIPS 95.391 to Y 0 CROSSSTREET _APN ?0--/70 -6Z PARCEL SIZE ZsWACLAND USE APPLICATION# OWNERNAME -T§jAIZK f smdrAiA 1�3 PHONE 2419,E-836261-934-1560OWNERADDRESS /7n T.2AGu ♦�/.VA�.SLIITE Q CITY/STATE/ZIP i CA ?'5-T7./ CONTRACTOR _TL�GrtA/nr/Y2IAG /AIC PHONE WJT`d SI.S� CONTRACTOR ADDRESS /81r;::� .4Ax we-s-r G t 1C l s /7X_ r CITY/STATE/ZIP ]1W,,lc.-'71"j'.j0 e-j4 -/S� a SUBCONTRACTOR 5A�.TIZUM C—Y�n"-rX)AJ - PHONE 2(jg- �A/s5- 03/2J SUBCONTRACTOR ADDRESS 2.465 /J/C-a"ismL.1c. CITY/STATE/ZIP 4S7T1X4-0M. 64 95Z05 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 9Z Z6sy EXPIRATION DATE Z O GEOGRAPHICAL INFORMATION: Coordinates X Y Township Z. S Range_ Section 3 C INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ater Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System 1 n If different from Owner: Water System Name Contact Name or Phone Number v \ TYPE OF WORK 94ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test.Hole ❑Other monitoring Well(s)_L#of wells ❑Soil Boringq of borings s) ❑Geotechnical #of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth Z$ 4 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter, / Conductor Casing Depth ft Well Casing Diameter 2- in Thickness/Gauge/ASTM Sc�hed IYD ❑Steel xlastic ❑Stainless Steel ❑Other Grout Seal Depth 7—//' ft XNeat Cement(94Ib bag/5-10 gal water) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped �,I ree Fall 11 Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Pa Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width —$ ft Length It Thick A/ in ❑Christy Box Atove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set _ R Standing Water Level It 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 11Neat Cement(94 lb bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water 11Bentonite 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 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 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT f AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIMU//�M� 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED C.OA.WA AS TITLE'�TA FF V&OLQC 157 DATE P Fill— -ji t F14 AI. H EP DEPARTMENT Application Accepted By Date Area � Employee 511 e"(� Grout Inspection By Dale 11 SPECIAL Well Permit 5//� Pump Inspection By Date ❑ WAIVER Received at Destruction Inspection By Date t Constructed Well/Depth ft COMMENTS n�zal a'-w [�,'.�{P]W�CQ C�, �(a,�/i'L-P ✓0/1 U/`)""/ ,97r -� YAlLN . A/lf0/p)/K (/Y) -I'(I t. /'AIj't- ldb PE SC Received heck# AmountDate PermiU Invoice# Well ID# Codes Info B ash Remitted Service Request# EHD 4302'006 MASTER WATER WELL PERMIT IMV2003