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W ELL / YUlV1Y YL/ MV111 SAN JJAQUIN COUNTY ENVIRON IENTAL HEALTH Dr-'RTMENT 304E WEBER A-'-3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PER LdALL 209 953-7697 FOR INSPECTIONS %+ TIRES 1 YEAR FROM DATE ISSUED JOBADDRESS \ ,\ - CITY/ZIP \]y\ r� 0 CROSS STREET i "OC IO\\,��a�� - rew\�a �e` APN_� 12j PARCEL SIZEy• / p OWNER NAME S CO `��\�\�\Q� \Y\�\ 'S� A� O 11PII__ON--E OWNERADDRESS �S' CQ �Vroqs�&mQ. CITY/STATE/ZIPS[ CONTRACTOR PHONE ` \\�`e\\�� \ ��\\N \ � PHHONE CONTRACTOR ADDRESS\`�� \V. C� l��\Y �yQ CITY/STATE/ZIPS�`�'.A�" n0. SUBCONTRACTOR `V VM TA, Q J PHONE TA, SN (\� SUBCONTRACTOR ADDRESS `" C� CITY/STATE/ZIP N \'N LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER l EXPIRATION DATE 11,� GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section 1`:n INTENDED USE O Domestic/Private ❑Irri AgncuIt al, OJnQustnal ❑Water polity Monitoring ❑Soil Sampling/Characlerintion Public Water System124W � yl mer teRa 1 - 1 Ifdiffemm from Owner. m eme omem anx o�l'moreNumber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other (� ❑Monitoring Well(s) numberofwells ❑Soil Bming(s) ""berofborings 13 Geotechnical number of boring 'O O Well Destruction ❑Out-Of=Service Well ❑Out-0f--Service Well Renewal ❑New Pump Xpump 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 ❑Gavel Pack/Gavel Size in diameter r� ❑Conductor Casing in diameter / Conductor Casing Depth It `Svv Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement .rack 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 ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width fl Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible Turbine ❑Other HP Pump Set fl Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gavel Pack ❑Uncased ❑Other Well Diameter in Total Depth R Depth to Water R ❑Casing to be Perforated from R to R Sealing Material ❑Neat Cement(941b bug/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap fl below grade ❑Complete to Existing Surface Pad I 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 CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. l NIMUM 24 HOUR ADVANCE N E REQUIRED FOR INSPECTIONS SIGNED TITL DATE\IQ y-D3 V W9Y U Ilk 111 r RT //JJ DEPARTMENT USE ONLY ''��7U1 ' Application Accepted By A-1*- JDi�f Date �b-.Q 7-0 9 Area )� mome IDg HOI '�o Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspect'Qn B L ��/JJi1�`—� Date O� ❑ WAIVER Received 7 Destruction Inspection By Date Constructed Well Depth rt COMMENTS PE SC Amount Chec Received Date P e r mitl Invoice# WeII IDM Codes Info Remitted ash B Service Re nest K 5 0 S 14133 7..L 1! 6 W35 EHD 43-02-006 MASTER WATER WELL PERMIT' 5nn002