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W r.L>L, � rulvar r�.xlv,�i� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPORTMENT 304 E WEBER AV FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PFRMIT t .LL 209 953-7697 F R INSPECTIONS I ]RES 1 YEAR FROM DATE ISSUED .I + JOB ADDRESS CITY/ZIP CROSS STREET 0C O 41 f, APN_ 41 / l PARCEL SIZE ^p� O - p OWNER NAME V rY r"f V Q dt de k f/ fg'� f^ _ PHONE .2�a OWNER ADDRESS <7 D W 1STATEILIP f * CO 7 4 CONTRACTOR J � A PHONE - CONTRACTOR ADDRESS CITYISTATE1ZIP 14 V SUBCONTRACTOR - PHONE SUBCONTRAC 1'OR ADDRESS CITYISTATE.IZIP LICENSE ❑rC-57 ❑C-61 O D-09 ❑Other NUMBER EXE'IRATION 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 System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification Cl Test Hole ❑Other number of wells number ofbor' F's ❑Geotechnical numberofborings 11 Monitoring Wells) _Sail Boring(s) Q ❑Well Destruction WOut-Of-Service Well z ut-Of-Service Well Renewal ❑New Pump ❑Pum Re lacement-" ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION t ❑Other Drilling Method ❑Mud Rotary ❑Air Rotary 13 Auger., . 0 Cable Tool ❑Push Point Proposed Well Depth H Excavation in diameter ❑Open Bottom 11 Gravel Pack?Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic Q Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hug 15-10 gal water) ❑Sand Cement sock mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method Q Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Install-ed By Q Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width tl Length ft Thick in ❑Christy Box .❑Stave Pipe PUMP Q Submemible ❑Turbine ❑Other lip Pump Set it Standing Water Level it WELL DESTRUCTION ❑Open Bottom 0 Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth Il Depth to Water ft_ ❑Casing tb be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hag/S-10gu1 water) ❑Sand Cement s•uZ-k mir 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped . ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑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. INIMUM 24 HOUR ADVANCE NOTICE REQUIRED f OR INSPECTIONS SIGNED TLE 4d&na- ISL —-- DATE I Y V i:_ I 1 C. N CO . q17 lit. o. I Y ?C 3 ]DEPARTMENT USE O Y L� Application Accepted By Area i e7 Employee ID# Grout inspection By Date © SPECIAL Well Permit r - '` -- " Pump Inspectibri-B": Date- Q- .-'---�❑ yAIVER Received. +. .=- -. Destruction Inspection sy ate dF Constructed ell Depth ft COMMEN ' PE SC Amount Cltcc 1 Rlfelvcd Date Permit/ Invoice# Well 10# Codes Info Remitted By Service Request# �`' SD L o0 351 Eli 0 43-02-006 MASTER WAILER WELL I'ERMI'I• 5/7/2002 Y