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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3P°FL-STOCKTON CA 952M - (209)468-3020 NON-REFUNDABLE PERMIT CALL092953-7697 FOR IN:PECTIONS EXPIRES 1 YEAR PROM DATE ISSUED JOB ADDRcn ' }}�' h F+e 1 '1' CITV2H Lfria[A (A "T cRDce srReLT VAIIIII, M1A APN 09 31 1400'1 PARCELSIEL'I�IO Aer4d 8 OWNERNAME ROALO 'a �• 3LAafttZ FIRM, 11 4167-- '1551 . QWNERADORES4 �5()7-•l �` r'\QIPU ST CITY/SEATE'Vie JTa LC -41L lel p 451 11-5 CONTRAC,UR _42 — /P.00NE/a/d COFCINACEORADDREX9 /19 CITY/STATP/ZIP T-/ nal? t/a eA JJ V7 suscOsrr.0 OR PHONE SUBCONTMCfOR ADDRESS CITY/SEATE/ZIP Lt.. 4C-57 0 C4 OD-N OOlhet NUMBER ZZ EXPIRATION DATE aVQ� GEOGRAPHICAL INFORMATION: Coordinates X Y Tonsahlp_ RwPf— Becilan INTENDED Use OOmesddPrivaM O Irrigation Agricultural 0Industrial ❑Wawa Quality Monirnring O Soil Sampling/Charactenataion O Pabhc Water 3 agr (� Ire R. Oen .mm ,um .m. Ters OF Woluc PNew Weil O Replacement Well ❑Well AIteratiOrl/MOdifialion OTeal Hole ❑Grier O Mooiwring Well(s) _ �vms..vr.dt. 13 soil Boring(s) nate etion., OGcotechnial ,unman bormF ❑Well DeeWcda 0Out-0f-Service Well OOuLOf-Service Well Rai O New Nnip O P..P R Iarri ❑Pump Repair O CrossC oscura R air WELLCONSr0.U— DrillingMe<hod 1Mud R�oQsary� OAir Rotary ❑ ge Aur 13 Cable Tool OPush PciN h 13Ot Proposed Well Depth SlIt Excavation /-a— in diameter ❑Open Botmm .IXGravd Pack/Grail Sin—in diameter ❑Conducts sang indianni / CuMucmr Casing Depth ft Well Casing 'Annan n ThicknesIJGauge/ASTM Schcd /f;d9 ❑Stal KPtesnc ❑Slainbas SRel OOMer Groin Seal Depth ft Cl Nat Cement 194/b Mg/S-IO gp1 wore J Cl State Cement .sack mu/7 gal voter XBentonile(20%solids) O Manufacturer Spec Y.solids % Name OSpason Fiie 09poes Submined Grout Placemeat Metbod ❑Pumped ❑Fra F911 13 Other ORetardant/Atamenemr(sume) PEDESTAL Initialled 8v ❑Driller vump Centractoc 13Oiher ❑ConcretePedesol Dimemlons: Width—A Length ft Thick_ in ❑Christy Box ❑Stove Pipe Pump ❑Submersible ❑Turbine ❑Other HP Pump Sen_ft Standing Water Leeel ft WELL DESTRUCTION ❑Open Bmbm ❑Gravel Pack ❑Uncaud LI Oth Well Diamnec in Total Depth ft Depth to War= I O Caring to be Perforate!fmm_R to ft Sealing Material 1Z Near Cement 04 1h Arg/3-fOgpl water) OSenl Cement sackmm/]gal Wler O Bemonite Pellets D Ber Anise Q08.lids) ❑Manufacturer Bp %wIids__% Name OSpeaon File OSpea Submitted Placement Methad ❑Pumped ❑Free Fall OOhec__ O Complete with Mushroom Cap ft below grade O Complete to Existial,Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, 1 ALSO CERTIPY THAT MV REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL Rat WOR KERS COM PENSATION LAWS, M INII"UM 24 HOUR ADVANCE NOTICE REQU[RED FOR INSrECTIONS-PLEASE CALL(209)953-7697 SIGNED V ZC/ /// TITLE IJ�(KJ'3 DATE 40-ro2 9 � Not, I.N11 DEPARTME ER APph.tnroo Accepted By a`^H Date It)—I,4 d3 Arca Employee lDk Grout lieweatent_ Dam /D—/y—U3 ❑ SPECIAL Well Permit PampinspaTion BY Dao ❑ WAIVER Received Dcstmcuun 1.%peetion By Date CoInionN ad Won Depth it Not, COMMENTS PE SC Reeewcal C ekpf Aratunt Dote Involcep Wall IAV C24ea lar. Beas Remitted ServlAe Re 1, 187 d6 0 650 a550- 133a- EHD43-02.006(CJy'ir3(/J L'A biro %Q&5- ////�"rG/j� /Q_�� MASTER WATER WELL PERMIT 2/ 1641002 Slap � // 9 ee A, �I/f//4pJ�'eIL 4045 4 L, !/ -60 44cek KO