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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH a TMENT 304E WEBS 3""FL-STOCKTON CA 95202 .(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 1-73.53 W 6-c"414-v� 11 1 JOB ADDRESS / f�/A� (d.^SO s's /�-�' CITY/ZIP MAaVktn,✓. �6be > CROSS STREET �r Ale 21x1 - 160- 1 2- PARCEL SIZE "R-/-r LAND USE APPLICATION # -f m OWNER NAME 1 rirlA"1� CoAAA4 LLA AIG S /� PHONE_&9_934)_ 1'l� y GWNERADDRESS �I i-1 I V�[J,�II'Ud. , SU.l� A CITY/STATE/ZIP Trc,r., / A f6-f p4+� CONTRACTOR _ C ,,A//)O✓r^` EC✓+1A Tr k 0'0 II05' 11 -�-t4�- PHONE '/L.1oq`Z ✓�qr p-�`Ca G7 CONTRACTOR ADDRESS 59:e � Q 1'/ r� r 1 IE�^f IK CITY/STATE/ZIP 154DLL-}71A t (_.A SUBCONTRACTOR � LAAk CX1L,I,brexDo ria-LAC_ PHONE Y7��1 ' y%Ri�E br7 - O'f �z. SUBCONTRACTOR ADDRESS Z OL7� W) IILO Uwe '✓(foG- CITY/STATE/`ZIP OCF-'m LICENSE Ij(C-57 ❑C-61 ❑D-09 O NUMBER V EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range;_ Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: water System Name C.rm.t Name or Phone Number TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other - XMonitoring Well4ofborings #ofborings (s) .Z.. #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 Drilling Method ❑Mud Rotary( ❑Air Rotary XAuger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth Z6 ft Excavation 6 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft W Well Casing Diameter __Z,_ in Thickness/Gauge/ASTM Sched HO '❑Steel Plastic ❑Stainless Steel -❑Other Grout Seal Depthit Neat Cement(94 lb bag/5-/0 gal water) 13 Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 1DkDriller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in - ❑Christy Box *Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level' ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack O Uncased ❑Other Well Diameter in Total Depth R Depth to Water ft ❑Casing to be Perforated from ft to. ft .*+ Sealing Material ❑Neat Cement(94/b bag/5-/0 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets r ❑Bentonite(20%solids) . 'OManufacturer Spec%solids- � -% Name - - . i7 Specs on Pile--O 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. I 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ SIGNED /��a+. �'] u'tib/�' = TITLE �"... DATE ,51 at _ f, ;7 yr{i pT N® 041 k4li-4TA L- , im DEPARTMENT USEPNLY + Application Accepted By �" L �"--+ Uaie�3 " rr S G S Area Employee ID# GUU Ajy —__ Grout Inspection By .Date - ❑ ,. SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth If 12 COMMENTS j"�- -� -60. ✓.ry �l,�0/ el" d, _, 0A_ F 2. ��/Y(�S�t- IV 'Cws— PE SC Received Check#/ Amount Permit/ �, Date Invoice# Well ID# Codes � -. Info B as Remitted Service Re uest# r3.cs (si 9cl17 IS`C Sr�ooy/�s2. EHD 43.02-006r �.M I^ MASTER WATER WELL PERMIT 1222/2003 r , t�