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WELL/PUMP PERMIT J—au a .',, W,1cpX t SANJ6.AQU1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVf 3't AL.STOCKTON CA 95202 -(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED /�/cu JOB ADDRESS ,p� CITY/ZIP d �L'L1 � tom- ?•- -T U SS CROSTREET r� A�w��•'� APN PARCEL SIZE OWNER NAME L(i�f�{ Ky�n�Ch Z?IloNyE,,,,�&l V„-t— In-�`�•�� 0 ER ADDRESS y ah ND. A9�,1r 1 i CITY/STATE/LIP �1mn (A�/'�-'•9�:alE? l I CONTRACTOR 1 04 j ��P,H,�ONNEE`"l+�.Q',—`'t CJf� —ge,4 T CONTRACTOR ADDRESS ,�,,��3za, �[X �rn VA CITY/STATE/ZIP LC.I C_y. }ice�`_'96 aft SUBCONTRACTOR�Y}/(11C_ 1'1/(��1,m .rP.IInOtN,,E,�q('�111—,1�� 1a�/tt0-1 G �1 SUBCONTRACTOR ADDRESS�2 - l�,lmM J CrrVfSTAATrdZZIP 9i7,i i L J \IX(Ii5`(�3.�AS 9' )y 4Q LICENSE UC 57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION,. Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Boil Sampling/Characterintion ❑Public Water Syy rem If different from O.v tt: rrer yslem ame mtacr Name or P one um TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altemtion/Moditication ❑Test Hole ❑Other ❑Monitoring Well(s)__ nomberofwdts oil Bormg(S) 10 nurbcrorborinas ❑Geotechnical "umb«ofbwiny ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service We11 Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Crass-Connection Repair WELL CONSTRuc-noN I Drilling Method ❑Mud Rotary p Air Rotary N Auger ❑Cable Tool ❑Push Paint ❑Other Proposed Well Depth. k5 H Excaystien_ �R_in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth `R Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth_I& R ❑Neat Cement(94 lb/rag/5-10 gal water) ❑$and Cement Tack MLY I7 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 ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width11 Length_ft Thick in ClChristy Bos O Stove Pipe PUMP 13Submersible 13Turbine ❑Other_ HP Pump Set fl Standing Water level Il WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth R Depth to Water Il ❑Casing to be Perforated train A to R Sealing Material ❑Neat Cement(94 th bqg/S-/O gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(2D'/.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 13 Free Fall dOther 1?_l0 GR' _' ❑Complete with Mushroom Cap D below grade. ❑Complete to Existing Surface Pad lJ 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN m 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 CZ WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE R,1tEQUIRED FOR INSPECTIONS ][�1 SIGNED TITLE t Y.tw rV� rte nyaA ,tQ �S�DATE •`� lir tj L:COL EEO ri TM LZ 7Z DEPARTMENT USE LV Application Accepted By Date Area r►l 1 !R Employee ID# r Grout Inspection By Date ❑ SPECIAL—Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspectio By Date Constructed Well Depth Tr COMMENTS_ e Xei-l/{d_!/Clj4Tf�5 Rrye� 0� j �k CI(C�iN-!a� Gvr G'Gt I�'Jrt' � �z,fl r' S�/✓t d /�� /�i,--e hdG_r . i,etfN. � 1 PE SC Amount Received ermit/ Codes Inf374 o Remitted ash g it ServiceRequest# Invoice# WelllD# O SO-007aq 000 I EHD 43-02-006 -- -- MASTER WATER WF.I I.PFRMIT