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Ir Yvr uiL, / 2'U1Ylr YEicynl J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT"' EPARTMENT /�D• 6,&t 304E WEP"^AVE 3au FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE P((ER[�MITy�.1„/ C�"ALL 2 V PECTIONS EXPIRES 1 YEAR /JFROM DATE ISSUED JOB ADDRESS IB J S M Q 1 r 1 1 I i y Rd CITY/ZIP /�/� w a CROSS STREET y1. APN /�/� 3Wz,/0 ' Z7r PARCEL SIZE—a-6-C, 4- 1Z-8 a OWNER NAME U t-Pry I /�1`,t (` L�n'zvfe o Em en/ /�k(, 9 i - z4a� PHONE OWNERADDRESS LMI M bayi 1`Q Loll l.lt "13 CITY/STATE/ZIP CONTRACTOR 1z/ PA)�IYSZ IL, PHONE CONTRACTOR •_,7 E{ n� I / C/'J CONTRACTOR ADDRESS_( =K-1-5 Ire— - CITY/STATEIZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -67 ❑C-61 ❑D-09 ❑Other NUMBER Z EXPIRATION DATE I Z V Z GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑IrrigatiWAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characteriretion Ao ❑Public Water System Ifdi Hemntfrom Owmr: Contact omeor rte um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberotwells f'Coil Boring(s) 2 numberorbodngs ❑Geotechnical number of borings ❑Well Destruction ❑Oat'-"Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair O Cross-Connection Repair CONSTRUCTION ... Drilling Method ❑Mud Rotary ❑Air Rotary uger ❑Cable Tool 0 Push Point ❑Other S Proposed 1O Depth 10 -1.5— ft Excavation —b in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 1 O ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gat water) ❑Sand Cement sack 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 R Length Fl Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set f1 Standing Water Level 11 49�DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Unused ❑Other Well Diameter in Total Depth D Depth to Water B ❑Casing to be Perforated from N to 11 Sealing Material ❑Neat Cement(941b bag/3-10gal water) ❑Sand Cement sack mix/7 gal water Bentonite Pellets �ryp7/L4y ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Speds Subm tted 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION nn —le' UIy1,i�HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNrn /C _.� i ,�11[[. . .y..m._._ ItiI�//V/7h./L DATE mwo I I FEN4WRr. RD. BRIGGS RD. ... MAAIU RD. O �� c0F 4 Ura-. .; LOVED + i rmr i 1 •+aa i NLD -> RD / sear+ Q aV. 5001 EX N Z D Iry I e• / - I .. - ..:_ 9� DE lIM.1 Rp,� 72' - _ �- ._ - 3 ® O , G�aosRE1s CO.Px. yg a Y z DOS REIS RD. g% %t':2 Q 0 F 1RDv� L2J;I1ro r �Z MDMSFEL. $ �•! 'moi mp IN. LOUIBNE '7 A . L'� drL y&ITE PLAN ®® ,O QQ )NLY ff11 Application Accepted By UVCW Date '� �— Area Z-� `7 Employee IDN Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date C nstruc d Well Depth f COMM TfSA/ PE SC Amount h / Received Permit/ InvoiceN well IDN Date Codes Inf Remitted ash By Service Request N 4)1L ISS 23c 1 116P 3 0030 Q59y�`l� EHD 43-02-006 MASTER WATER WELL PERMIT Sn/20o2