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lb/,rl whut, / YUN1Y mKivn i Or" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH',--.RTMENT 304E WEBE' 'E3""FL-STOCKTON CA 95202 - (209)466-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS *-ieXPIRES 1 YEAR FROM DATE ISSUED y JOB ADDRESS l 2— C � �- G�sSD �"F- CITY/zIP t-6.46rap 95330 Y 0 L RCA _ APNPED ��'- PnnceL SIZE CROSS STREET r_ Myy�'''llL; — A [ONE OWNER NAME OWNERADDRESS ZIP C 37 677 CONTRACTOR am( ED TIBC PHONE /_�J, �.V<'-t-3Z CONTRACTORADDRESS Also �Aey fkLVD CITY/STATE/ZIP r r�CA / 953711 V , W SUBCONTRACTOR T9 f �ItiY' PIIONE- / I SUBCONTRACTOR ADDRESS 3119 SF'ICQ•S rG PLITY/STATFIZIP �� 'fQ2.QJ2. jp LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER3QEXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring $Soil Sampling/Characterization ❑Public Water System If different from Owner: water sytim,No.. Com.,N nme or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole 11 Other 'wipea4a� ' y-8 number of wells number of borings number of borings 13 Monitoring Wells) num ❑Soil Borings) ❑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 )Q Push Point ❑Other Proposed Well Depth 'Ao-" ft Excavation �L in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hag/5-70 gal water) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted 4) Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller O Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other O Well Diameter Z in Total Depth_5 it Depth to Water It ❑Casing to be Perforated from it to ft h Sealing Material KNeat Cement(94/h hag/J.10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(206/o solids) ❑Manufacturer Spec%solids o/ Name ❑Specs on File ❑Specs Submitted a Placement Method ❑Pumped III Fall IKOther ❑Complete with Mushroom Cap tl below grade ❑Complete to Existing Surface Pad I�IrI 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 WIT THE CALIFORNIA CONTRACTORS STATE,JLI�C�,fNSE BOARD ANI? THAT I AM IN COMPL14NC WITH ALL WORKERS COM T AWS. rfV /fla'-s Z IMUM 24 HOUR ADVANCE NOTICE REQ L QUIRED FOR,11 SPECCTIONS SIGNED TITLE rtyi Cd ifACM' DATE C'5- Ir 7 \ 4 Q•%wl1 aT �� a ! s At IN� - ! t s 6 + + ° o 5 wo s DEPARTMENT US Application Accepted By Date /If Area `.>.�/ Employee ID# �� Grout Inspection By Dale ❑ SPECIAL Well Permit Pump lnsp I By ❑ WAIVER Received ns ecnon Destruction �I)ate� fg�istrnet th COMMENTS 7 --�J 4 L2 -w�` e(ue P_—S7 C zw-It--v4o two aYfecE-e C OL fU C6 eY{� PE SC Amount Check#/ Received Date - Permit/ oice# Well ID# Codes Info Remitted s BY Service Re uest# Lfi.� (Sc '30.00 1311 tffqS4G )c `ftJ4'73 EHD 43-02-006 MASTER WATER WELL PERMIT Sn12002