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_ QW LL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D TMENT - 304 E WEBEW FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED fA JOB ADDRESS / 35 -+ CITY/ZIP 12dG4 CROSS STREETt�fQF.,Q,r' f /COATI APN Z�-/(Q -�2 PARCEL SIZE ,AND USE APPLICATION# xf OWNER NAME /P/MAl2V f ^rimf4l Jl TIFf PHONE OWNERADDRESS 31120 -71tALVLLIb 1 CLl/Tf_ ,Q CITY/STATE/ZIP -7&eI 9 5376 CONTRACTOR l AM;p 29&e7m 77 A— AALe3&16S, 1AIC PHONE 241.2W-01c1 � CONTRACTOR ADDRESS .1 fl t F/�.AA& 111 f-r ,� 511725 _ CITY/STATE/ZIP 1�.�� gfZ0 SUBCONTRACTOR -5/E'r7F-MM PHONE SUBCONTRACTOR ADDRESS Z3(,5 Lt),1 KIAM /)/2 CITY/STATE/ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE JO GEOGRAPHICAL INFORMATION: Coordinates X Y Township 2_5 Range-4 Section -3 INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑IndustrialWater Quality Monitoring ❑Sail Sampling/Characterization ❑Public Water System INlifferent from Owner: water System Name Cmmsct Name or Phone N.mb.r TYPE OP WORK XNew Well ❑Replacement•Well ❑Well Alteration/Modification ❑Test Hole ❑Other IAMonitoring Well(s)---L—#of wells ❑Soil Boring(s) Nof borings ❑Geotechnical Nofbmings ❑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 —2 6' ft Excavation in diameter ❑Open Bottom 13 Gravel Pack/Gravel Sizein diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter zf,in Thickness/Gauge/ASTM Sched_,#o ❑Steel Alastic ❑Stainless Steel ❑Other Grout Seal Depth CI -//f ft . t�rveat Cement(94 Ib bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) /❑`Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped XFree Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed B MDriller ❑Pump Contractor ❑Other ZV Concrete Pedestal Dimensions: Width ti� ft Length n-r ft Thick 11 in - ❑Christy Box Stove 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 ft ❑Casing to be Perforated from ft to ft Sealing Material 13Neat Cement(94 11,bag/5-10 gal wafer) ❑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 1 ❑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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ,Q' T r TITLE T.4FF�+FJiL/3Q./{7 DATE I / DEPARTMENT USE- A Application AcceptedBy / Date Area 2 (Pn Employee ID# �-// Grout Inspection By Date 11 SPECIAL Well Permit 7t Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS / —Al /) W a (kii1/ C MK lZw - Fj60� 641 -ef�;c t� Lnrl d PE SC Received Check# Amount Date Permit/ Invoice# Well[D# Codes Info B ash Remitted Service Request# s /I END 43-02-006 MASTER WATER WELL PERMIT IL312003