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� VVJU,l,l, / rVlvir ri',iuvii1 SANJOAQUIN COUNTY ENVIRONMENTAL HEALT 7PARTMENT 304E WEer AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT "— CALL(209)953-7697 FOR INSPECTIONS _.&XPIRES 1 YEAR FROM DATE ISRMW � JOB ADDRESS 40 Z T qW t.• CITY/ZIP 54oc.KipA 'O> I :4 1�3-210-051 t-to-vo—o6 v CROSSSTREET OwoLS Nor—, APN 173-ZID-Iiy I IT3-LID—D7- PARCELSIZE H 'a9 Ac_ A OWNER NAME �f e A I� �nYAd� � PHONE,/,2 oG-y(�� 3Q-6G0'61� OWNER ADDRESS 3/25 15 W- fAL, 1 ST(IYY[I' CITY/STATE/ZIP 5�DLl1FpY; . �A 915141 CONTRACTOR CdkrIcr -(h r[(L1lMIDQ SCS L PIIONE SDI 1i ` CONTRACTOR ADDRESS' gO(n�fT1Hr�.h �C (,!(If �`I ; L J.. CITY/STATE/ZIP N*C.��4/b&II Cf' 95 z()1� SUBCONTRACTOR J il V3 PHOONE �,•-/l� / / —L41 00 �1 SUBCONTRACTOR ADDRESS I CITY/STATE/ZIP 1--�--5 UCA ny I q54L4 I AZO D EXPIRATION DATE LICENSE {1(C-57 ❑C-61 ❑D-09 ❑Other NUMBER 'IDI � 2lDD� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section rn INTENDED USe ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring (Soil Sampling/Characterization \11 ❑Public WaterSystem Ifdtffi:.m from wnee Water System Name Contact Name or Phom Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wens number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) Do Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New 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 10-20 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel Cl Plastic ❑Stainless Steel ❑Other Grout Seal Depth It ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement suck 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 11 Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP _ ❑Submersible ❑Turbine O Other His Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Tota]Depth tl Depth to Water tl ❑Casing to be Perforated from 11 to fl Sealing Material Neat Cement(94 th bag 15-10gal water) ❑Sand Cement sack mix/7 gal water 11Bentonite Pellets ❑Bemonite(20%solids) ❑Manufacturer Spec%solids % r�Name ❑Specs on File 11SpecsSubmitted Placement Method Pumped ❑Free Fall ,Other acKrlk UYe46. t55tIMS %( A.6DDL lA7pyrj"T 13 Complete with Mushroom Cap_ft below grade ❑Complete to Existince 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. I 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. MINI_MUMrM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED �s�✓` ✓ TITLE JTf�Y-1r ('JGt7 IPJ,�l i ST DATE � '3'V3 Y aF R a a n A A x A R v st 9 B R R a x R % g ayoH u� e e a o a s � a iguDRr a e as aJ " PJ/{-,\ O S UB I 1 I/ %a o : a aca R' x EN a a R e F A S e R F A B6 a .v r R ■ a a a a a A U (, Application Accepted By t e^R o r v - Area� Employee IDN / / ` Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received lmcnon Inspection By Date Constructed Well Depth it COMMENTS PE SC Amount heck#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Service Request# 57 1 S— 303 s�d 3Sv EHD43-02-006 MASTER WATER WELL PERMIT sn12002