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/(/.go/I W W L' LL / rU1Vlr rl.' ninji 1 SAN JOAQVIN COUNTY ENVIRONMENTAL HEALT UARTMENT 304E WET -AVE 3u'FL-STOCKTON CA 95202 - (209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED O JB � � � A . L CITY/ZIP SA=KadA y '^ C ` 10-05 1-72-W1-72-W-071-72-W-07o ol��. CROSS STREET `1� 1,W1 C._`kP,Y L(/h^�' 11 ppAPN 1'I'.j-Z 1 p-0(! �P/A�RCCEE�L SIZEQr��`�yA�2'{-/ •l p OWNERNAME //JJ�rr'1TO.ryC 1�40(✓�l � [lyl S�l t/1 PHONE 1/L�+/'1 �f+-�s1`rJ Q7 -1y o' OWNER ADDRESS lgq'4 a RA,-,l DeLkQ CITY/STATE/"ZIP SOC-P'-pl/\ M1 '-'l CONTRACTOR PHONE �- 23q- 6SVQ'�/ UCONTRACTOR ADDRESS I _ It' CITY/STATE/ZIP <..7TO(�V�I CA g5ZC6 SUBCONTRACTO0. LYA1N1W � f0.a o( tw � PHONESoe(- 5q!5— Idyl SUBCONTRACTOR ADDRESS K.o\&oAA\ ey6 CITY/STATE/ZIP AJyl., OlL cm- R v LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER , ] EXPIRATION DATE ' GEOGRAPHICAL INFORMATION: Coordinates X Y 1'Z' -Z� w Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Q(Soil Sampling/Charzcterization ❑Public Water System _ Ifdiffere tfim.0uner water ynem ame ontacr nmeor one Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification 0 Test Hole ❑Other ❑Monitoring Well(s) number of wells 13Soil Boring(s) no berrofbodngs Rl Geotechnical .'�l�°tuber of borings ❑Well Dwiruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ^•� ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary 0 Air Rotary "Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 10-my R Excavation in diameter ❑Open Bottom O Gravel Pack/Gravel Size in diameter --•l ❑Conductor Casing in diameter / Conductor Casing Depth ft 0 Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941b bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(201/6 solids) ❑Manufacturer Spec%solids e/ 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 tl Length_R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set fi Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased AOther Well Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from ft to )t Sealing Material Neal Cement(9416bug/5-10gal water) ❑Sand Cement suck mix/7 gal water O Bentonite Pellets r ❑Bentonite(20%Solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method I(Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT i 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE 5111-14' 6ecl �ST DATE I OILI 1 uZ rul�l� MAlrl _.._. ..,.... _,..__. gltr(ro') gllr (to,) I$ 1 �!Z .lre9 R11 NTYtR ICES w,l _ -- P,Y `"-`ID , RtI $ ru') e�Nuty 1 3 eC JIB es\�\.- �_- —1 - A� Q!l�11p'(pp,, DEPARTMENT USE ONLY Application Accepted By V LIAAX V"M!L xA,- Date 10-1&-0-0 �' Area Zl l Employee ID# J Y Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received n Inspection B*-' �� '� Dale f1�l�/02i Constructed Well Depth it COMMENTS YG> ZD6 Yd $c9Z rl6< rl'Ir_C-J/i-v>rf C_4�"* r f;� 'Zt�.ifJ�sJ ld��at,/.iV'<X'tGrl_)G.y7siGccTli+�6s PE SC Amount Check#/ Received Date Permit/ Invoice# Well IDN Codes Info Remitted ash By Service Request# i 15-0 130 -S5-7szf Z,6a 3 - l . EHD 43-02-006 MASTER WATER WELL PERMIT 5nn-)002