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WELL / PUMP PERMIT --Asazwe� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIIYCPARTMENT 304 E W EBIt. AvE 3"a FL-STOCKTON CA 95202 - (209)468-3420 NOr'il-REF't'NDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED J08 ADDRESS L/70 Z b CITY/ZIP 7//� 1J� / ✓�� y CROSS STREET .l�".y J��/� � /��I�iV /��/[/}'AYr��+sYynTA.�APN I 3 "Z-/f)-.r,O� PARCEL SIZE OWNERNAME //!/r"J' 77F-(.,�1�f�✓T {^`�Y—J�/IVCs- \ R /,V` PHONE M�JJ� m OWNERADDRESS �/!J/-�l�L s� �7�/-.� /`- �/�- CITY/STATE/ZIP n�g/Z CONTRACTOR /17l/rf!e'lmw�N a a /jam PHONE{ �d7-31— CONTRACTOR ADDRESS .nC I. �C.��C�C�/1'C /�� CITY/STATE/ZIP /✓"-�''� c �J� �S SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS .DEITY/STATEIZIP I---------- LICENSE 5761 13D-09 ❑Other NUMBER EXPIRATION DATE �� U GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Samphng/Characterization ❑Public Water System If different from OwnerWater system Nam onus Nam or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(s) numberofborings ❑Geotechnical numberofborings Ch ell Destmction [IOut-Of-Service Well ❑Out-Of-Service Well Renewal s ❑New Pum ❑Pump 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 Size in diameter J ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gut water) ❑Sand Cement .tack 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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level It WELL DESTRUCTION en Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Tom]Depth it Depth to Water ft ❑Casing to be Perforated from tt to tt Sealing Material ❑Neat Cement(94 1b bag/5-I0gal water) and Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) 0 Manufacturer Spec%solids —% Name ❑Specs on File O Specs Submitted Placement Method ❑Pumped ❑Free Fall �ther Y/•-/—z"`+ at7��/At- �✓� ❑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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI /Jy/JI�7M 4 ,IQ/JADD)VA�N�CE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)95 -769 SIGNED s.?!�'6 k t!sl�C'f"Pf'/a 1 TITLE f�'�e _7 ' DATE c� r AAA I N ) E NJ A UI E ARM N DEPARTMENT USE O L Application Accepted By Date Area Employee ID# [° Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By z Date / ❑ WAIVER Received / N' Destruction Inspection By s Date Constructed Well Depth ft COMMENTS PE SC Received ChecWB AmountDale PermiU )nvoice# Well ID# Codes Info B ash Remitted Service Re uestis Lf --7 /�( 3 8 iso- s--0 ' o S Q7367q EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002