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WELL/PT"IP PERMIT SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEPAREMTIT _� 3Wi.WEBER AVE 3a"FL-STOCKTON CA"202 -3420 NON-REFUNDABLE PERMIT CALL 209)953 fte7 IT3R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m JOBADDRESS ZS800 N. /Y1 � a-'�R_. RA. Cm2v C'1men's' y �Y R-'2 0 '�f O CROSS STREET L��` 1 LAPN 'I/13 01/y OJ PARCCL$ILC V / Am OWNER NAME F 4plons /lFl..�"e Rd ld 14; f4 -b/51/`I(.Y PHONE(�/D� 9iSb �n / A p OWNER ADDRESS 'q 7� 1111* �'} CITV/STATEJZIP—l� rQ 11007 CONTRAQOR PHONE CONTRACTOR ADDRESS CITY/STATEIZIP SUBCONTRACTOR PHONE $UBCONTRAcTORADDRESS CITV/STATE/ZIP LICENSE ❑C-57 ❑C61 ❑D-B9 ❑Olhtt NUMBE0. EXPIRATION DATE GEOGRAPHICAL INFORMATION: Cre rdiratH X Y Township_ Range_ Section INTENDED USE O Domalic/Pivate ❑ImgationiAgricullunl ❑Industrial 0 Water Quality Morisonng Cl Soil Sampling/Characteriration O Public Water Synem Hememii Dom Pxrar. .m nNm aaa -two .testa P..Nurnts, TYPE OF WORK ❑NeW Well O Replacement Well 0 Well Alteration/Madihcinum ❑East Hole 0Other O Monitoring W.11(s) namberof.db 13 Soil Bming(s) nvmeeroraonnsa 13GemahNral number of borings O Well Destruction OOut-0f-sc kc Well 0Out-Of-Service Well Renewal Tex ew Pump ❑Pump Riplecarriont O Pump Repair 0 Cross-Connection Rem ' WELLCONRERUMEM 'b DriWng Method ❑Mud Rotary 0 Air Rotary ❑Auger 0 Cable Tool O Push Paint 0 Other Proposed Well Depth H Excavation indimnescr ❑Open Bottom ❑Gravel Pack/Gravel Si. in diameter ❑Conductor Cuing in diameter / Conductor Casing Depth 11 Well Casing Diameter_in 'Hicknes✓GaugeJASTM Schad ❑Slal ❑Plastic 0 Stainless St.) El Other Grout Seal Demh Il ❑Neat Cement(94/A M•g/5.10 got wnmr) 0 Sand("'oen1 .nrk mit 17 gni writer 0Gentonne(20 solidr) O Manul'acwmr Saec%suida % Name 0SDcesun Pile 0Slaves Suhmiued Grain Plarrmenl Method 0 Pumped ❑Free Fall 0Other ❑Retardant/Accclemmr(name) PEDESTAL Initialled By ❑Driller 13Pump Contractor ❑Other ❑Concrete Pedesml Dimensions: Width—ft Length R Thick in 13Christi,Boa ❑Stove Pipe Ft IGmersible [3 Turbine ❑Other HPACID— Pump SC - H Standing Water Level R WELL DESTRUCTION ❑Open Bottom 0 Gravel Pack ❑Located 0 Other Well Diameter in Tom)Depth R Depth W Water R 0 Casing to be Perforated 1'mm 11 1. It Stalls,Material ❑Neal Commit f94/A Wg/5-/0 galamer) ❑Sand Cement rarkrnu 17 gal Water O Bentonite Pellet ❑Bentonite(2O%solids) ❑Marotinomer Spa%solids % Namc ❑Spas un Filc ❑Spas Submincd Placement Method 0 Pumped ❑Fra tall D Other ❑Complete with Mushroom Cap B below grade 0 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. MMU R ADVANCE NOTICE REQUIRED FOR INSP/-E-�CTIONS/—PLEASE CALL(209) 53- � fi97 $IGNEn Nom+^�• TRLE SGaIie/C•V r/ E /a"eer DATE J `? h` 5 Mc1D•,r DEPARTMENT IIS 19 ��ptfEN Application Accepted By Date Arca EmploRril r Grain lnspation Date ❑ ECIAL Well Permit 79 Pump lnspaG By �-� Dal .dv�S� ❑ WAIvERReceived Datmmian Inspection D Date caaao-aeted win Depth n COMMENTS ' — PESC Received Ch / un DolePeemly Invoice# Well IDN Lades Info B ulr He t d Serybe, Resistant p O 33 SR00329-39 rilD 43.024106 MASTER WATER WELL PERMIT