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414821 WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL41TEPARTMENT 304 E WEIIPAVE 3"FL-STOCKTON CA 95202 - (209)469-3420 NON-REPUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED h JOB ADDRESS_ 9355 W. Highway 4 CITY/ZIP Stockton 95206 s v CROSS STREET Delta Road APN 131-090-21 PARCEL SIZE I.s2 LAND USE APPLICATION# A 4G OWNERNAME Ayesh Ayesh PHONE 462-2976 OWNERADDRESS Same CITY/STATEIZIP CONTRACTOR Delta Stockton Pump PHONE XUWJJM 466-9625 CONTRACTOR ADDRESSftX=U fXffiW 646 S California St CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIITY/STATEIZIP LICENSE OC-57 IMC-61 ❑D-09 12i Other NUMBER d?A EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ INTENDED USE ❑Domatic/Private O Irri tion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterintion Sl Public Water System tion/Agricultural ��'-Gi LA)-5 If Mnerem from Owner: Water ystem ame ntcet Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of bonne, ❑Geotechnical s of bonng" ❑Well Destruction ❑Out-Of-Service Well ❑Out-0f--Service Well Renewal ❑New Pump EXPump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sin in diameter ❑Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 111 bag/3-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped ❑Free Fall ❑Other 13Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width it Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP M Submersible ❑Turbine ❑Other HP 1 Pump Set 30 it Standing Water Level 10 11 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other CC Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from R to ft l' Sealing Material ❑Neat Cement(94 Ib bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets a ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing 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. 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 09/10/04 SIGNED 7 TITLE 99 CEO DATE G E r AH DEPARTMI NT USEVNLY Application Accepted By Date Area o2( Employee ID# pl t'4 /9l� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection Bp (�lL.!/, Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check# Amount Date pc. Invoice# Well ID# Codes Info B s Remitted Service R uest# H3s� OSI x{23 7SC-0 DO RCO 3`i ��i EHD 4142-0 MASTER WATER WELL PERMIT 122MM3