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WELL itI"O"PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 I NON-REFUNDABLE PERMIT 1f CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ^{�� G, y JOB ADDRESS ©D �I -/Cl`r t f c_- Irl. CITY/ZIP l Y 1� ' �' 1"10. to C CROSS STREET !✓� y C�'/f�/l f APN Yy^�S PARCEL SIZE a • R y�7 Sri^; OWNER NAME !Q 00/ L \ Vi C PHONE OWNER ADDRESS �{��J�J(�f^t�./ r T92 f =`Y�r CITY/SI'ATFJ"LIP CONTRACTOR {Yly/a-C- /�1S r)'_l PHONE—::�-2/4? CONTRACTOR ADDRFSS l ' ! I iLp✓--f C CITY/STATFl7.IP-/40%/O(1-Pf r SUBCONTRACTOR IPHONE SUBCONTRACTOR ADDRESS CITY/STATFJZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER �J� EXPIRATION DAr6'2 -00 GEOGRAPHICALINFOR.MATION: Coordinates X Y Township Rangc___ Section I NI'ENDeD USE ❑Domestic/Private ❑Irngation/Agncultural ❑Industrial ❑Water Quality Monitoring ❑Soil Samplriinng/Characterizallion �(I Public Water System r )J I rt?I,) �s e�r \ !P P. Sy Ifdirfere 1F-0b er rf mer stem •me mac honcT7 TYPE Or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole Other / R. numberufwells 0 Soil Boring(s)s nwnberofbon ngs p Geotechnical numberofbonngs ❑Monitoring Well(s) _ 8O— _ (\ ❑Well Destruction ❑Out-0f-Service Well ❑Out-0t-Service Well Renewal V ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair Ir O ELL CONSTRU(YION Drilling Method�ud Rotary ❑Air Rotary ❑Auger`s 13 Cable Tool O Push Point ❑Other Proposed Well Depth,_it Excavation___in diameter ❑Open Bottom >Gra vel Pack/Gravel Size_ ._ in diameter ❑Conduct a ing in diameter / Conductor Casing Depth__11 u Well Casing Diameter in Thickness/Gauge/ASTM Sched .200 ❑Steel W—Plestic ❑Stainless Steel El Other . al water Q Grout Seal Depth- tl ❑Neat Cement(94 1h hug/5-10 gal wafer) 'Sand Cement /[)' 3 cockmR l 7 B D4tt{411 R1 }! ❑Manufacturer Spec%solids % Name ❑Specs ou File ❑Specs Submitted 'lIt\i Grout Placement Method XPumped 13 Free Fall ❑Other ❑Retardant/Accelerator(name) J ' EDESTAI. Installed BV ❑Driller r'�Qlump Contractor 0Other_- Concrete Pedestal Dimensions: Width_=_ Length n Thick ` in 0 Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine O Other HP Pump Set H Standing Water Level it WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack O Uncased ❑Other Well Diameter in Total Depth _it Depth to Water tt ❑Casing to be Perforated from R to R Sealing Material ❑Neat Cement(94/h hug/5-10 gal water) ❑Sand Cement sack rnfr/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File O Specs Submitted Placement Method ❑Pumped ❑Free Fall D Other O Complete with Mushroom Cap H below grade ❑Complete to Existing Surt'ace 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS t rn Q�� SIGNED TITLE ` ,r,ll 1A DATE e c N � i a _ o EP TH EN\'IRONtit='A DEPARTMENT USE N L/ Date U Area Employee IDp _ OO Application Accep By O Grout Inspection By _ _ Date [I SPECIAL Well Permit Gj Pump Inspection By _ Date ❑ WAIVER Received Dale Constructed Well Depth Destruction Inspection By fl COMMENTS _-- ---- PE SC .Amount eck# Received Date Permit/ 11 voice ft Well IDN Codes Info Remitted By Service R uest p Y3&YI& SG— G - olo�a65 0� MASTER WAt ER WELL PERMIT EHD 43-02-006 5/7(2002