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VV LLL f A V lyaa A a'/a4ui a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT' nEPARTMENT 304E WEBF^AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420. NON-REFUNDABLE PERMIT CALL(209)953-77697 FOR INSPECTIONS EXPIRES 1 1YEAR FROM DATE ISSUED JOB ADDRESS \1 — l\ \\\\n:' ��0. r CITY/ZIP CROSSSTREET APN I-73- 300- 08 PPARCELSIZE f, A OWNERNAME `YV V. �m�rto �r PHONE OWNERADDRESS1CITY/STATE/ZIP CONTRACTOR �W` hCO�\� V'Lh i.]T�, V \ \\TQ„ PHONE: `-'z 'z�^* CONTRACTOR ADDRESS ,\11LM CITY/STATE/ZIPI:— SUBCONTRACTOR `\Vl \� PHONE '� SUBCONTRACTOR ADDRESS •_ \s(X CITY/STATEIZIP LICENSE C-57 G61 ❑D-09 ❑Other NUMBER ` EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ ,Section. INTENDED USE meslic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If differcm fmm wnee nmr ysum o. onmd cmc or one um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of writs 0$011 BOrIn numberofborinss ❑GGOtechnieal numberofborinxs C ❑Monitoring Well(s) g(s) ❑Well Destruction ❑Out-Of-Service Well. ❑Out-Of-Service Well Renewal ew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION '- Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth H Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim—in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _in Thickness/Gauge/ASTM Sched _ ❑Steel ❑Plastic ❑Stainless Steel O Other Grout Seal Depth fl ❑New Cement(94 lb bag/5-10 gut wafer) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(2(r/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_ it Length_R Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP Pump Set H Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth R Depth to Water It ❑Casing to be Perforated from R to R Sealing Material ❑Neat Cement(94/b bag/5-10gal water) ❑Sand Cement suck Infix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_a/ 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN WITH ALL WORKERS COMPENSATION LAWS. \fes 1 [MUM 24 HOUR ADVANCE N(YTrFREQUIRFQ FOR INSPECTIONS SIGNED v \\� TITLE `DATE �as-o3 C N AL rte, ( DEPARTMENT USE ONLY '] _ Application Accepted By lyu V &kk a/ Date 3 '- )S Area Z1 Employee ID# Grout Inspection By ))) Date ❑ SPECIAL Well Permit Pump Inspection Date, ��' ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COMMENTS PE SC Amount heck#/ Received Date Permit/ Invoice# We111D# Codes Info Remitted as ty Service Re acs[# 4380 Mo 5 Sb J 2� U3S 00331 7 EHD 43-02-006 MASTER WATER WELL PERMIT 5nnoo2