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;112558 WELL /PUMP PERMIT I SAN JOA#25 COUNTY ENVIRONMENTAL HEALTHi ,�1RTMENT 3{14 E WEBEk+'`k�E 3"'FL-S'roctErON CA 95202-- (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS .;XPIRES 1 YEAR FROM DATE ISSUED French Cam 95231 M Road CITY/Zip D y JOBADDRESS 360 W. Bowman �] / F o ,�t APN(_4 (1 t Z PARCEL SIZE ' Iy CROSS STREET r OWNER NAME Consuela Noce' * PHONE 982-5839 OWNER ADDRESS 'same CITYISTATEIZIP CONTRACTOR Delta Stockton Pum PHONE 466- 625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton C 995203 PHONE SUBCONTRACTOR lCITYISTATEIZIP SUBCONTRACTOR ADDRESS LICENSE [IC-57 ❑C-61 El D-09 ❑Other NUMBER 724778 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE M Domestic/Private ❑lrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization 0 Public Water System If different from Owner: ater System ame omact ame or one um er TYPEOF WORK ❑New Well 0 Replacement Well ❑Well AlterationWoditication ❑Test Hole ❑Other numherofborings number of wells number of horiags 13 Geotechnical❑Monitoring Well(s) El 5ail Boring(s) [3 Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 7 ❑New Pump ffPum2 Replacement ❑PUM2 Repair ❑Cross-Connection Repair WELL CONSTRUCTION f Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 11 Other [� Proposed Well Depth ftExcavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth Well Casing Diameter in Thickness/Gauge/ASTM Sched CI Steel ❑Plastic ❑Stainless Steel ❑_Other Grout Sea] Depth ft ❑Neat Cement(94 lb hag/5-10gal wafer) ❑Sand Cement .rack rnix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name C]Specs ori File ❑Specs Submrttedf. + � . If Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) 1 24 94 PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other y nty 11 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Chrls;y Box ❑ re Plpe G PUMP M Submersible ❑Turbine ❑Other HP 1� Pump Set 105 h St�nd�ng Wa gr Level k 2'� tt WELL DESTRUCTION 11 Open Bottom ❑Gravel Pack ❑Uncased ❑Other r + G Well Diameter in Total Depth ft Depth to Water tt ❑Ca t�I'etorated trom ft to ft Sealing Material ❑Neat Cement(94 lb bag/S-!0 gal water) ❑Sand Cement scrik rnu 1 1� hater s ❑Berltantte Petlets t �. r r ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name CI Specs n!: File• ❑Specs Submitted ' Placement Method ❑Pumped ❑Free Fall 0 Other t ❑Complete with Mushroom Cap ft below grade ❑Complete"isting Surtace,Pad „: .040 I HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WdI LOBE DONE IN.VXCORDAHCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO xCERTiFY- THA REQUIRED.,LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND,THAT i AM COMPS IANCE WITH ALL WORKERS COMPENSATION LAWS. UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS. . SIGNED TITLECFO DATE 1i/15./02 d r I f � 1 KILIN I I FIE 2E p y \-/I\,- AN JOPUU1'I i 1 _r - O- - DEPARTMENT IIS -e -- - - - - -NLi' Application Accepted B Date Area Employee IDN i — Grout Inspection By Date ❑ SPECIAL Well Permit i Pump Inspection y G- `f !�/ri Date ld/d -,Z ❑ WAIVER Received Destruction Inspection4> Date Constructed Well Depth It COMMENTS a • PE SC Amount Check#! Received Date Permitl I"voice# WeIIID{i Codes Info Remitted f�as h By ! h Servpi�ce Request# EHD 43-02-006 MASTER WATER WELL PERMIT 5nn--2002 4 {