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WELL/ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED �3 � �tENN 1� gid; 9�0 ORA, CITy/ZIP D /1 I, �\\/ O CROSS STREET (�(��f} , APN I _ 1 V V V r0�--1 �/ _ B PARCEEL SIZE. �/6y L OWNER NAME - W 91 S 46f0k, 1iJ� J 1 PH ,J ONE ILI G/ L_ -7 + OWNER ADDRESS Sn'I /ly 850CfiYI$rATE/ZIP�,l. P ►�c' —.1D, [�v_^/ , CA 75zf U CONTRACTOR � t PHONE f�(- .3 [— CONTRACTOR ADDRESSZ Z N r�0 fir, 01 Q�!2,40 C �Ci S SUBCONTRACTOR �- prypryE SUBCONTRACTOR ADDRESS_ CITY/STATE/ZIP _ m LICENSE C-57 0 C-6i ❑D-09 0Other NUMOEH r.K.i�- 00 EXPIRATION DATL O 3 GEOGRAPHICALINFORMeTION: Coordinates X Y 'Township Range SeClba _ INTENDED USE Q OOmCSUCIPTi}ale 0 lrriganoiVAgricuhural 0Industrial 0 Water Quality Monitoring Soil Sampling)Chamcicnza tion 0 Public Water System Ifdifferent from Owneraia >srim amc oma�Came o one N—Ix, -" TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteraiion:Modificatton Q Tesi Hole ❑Other O Monitoring Well(,) _ --berorwcua )(Soil Borings) Z' nambar"rb.ri ap ❑Geotechnical__ "umber or borinty O Well Destruction 0Oua0f-Service Well 0Oui-Of-Service Well Renewal O New Pump 0 Plump R lacemcnT 0 Pump Repair G Cross-Conner(tort Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary O Air Rotary 0 Auger El Cable Tool O Push Point 0 Other Proposed Well Depth 15-2-0 R Excavatior.. &M to diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diam-ter / Conductor Casing Depth tl Well Casing Diameter_in Thickness/Gauge/ASTM Sched Cl Steel 0 Plastic ❑Stainless Steel ❑Other _ Grout Seal Depth fl ❑Neat Cement(94 1h hag/5-10ga/»Hier) 0 Sand Cement .cock mix/7 gal water 0 Bentonite(20%solids) 0 Manufacturer Spec%solids_% Name i 0 Specs on File 0 Specs Submitted Grout Placement Method 0 Pumped 0 Free Fell 0 Othet_ O Reu,rdant!Accelerator(name) PEDILWAL Inslalled By 0 Driller 0 Pump Contractor 0 Other 0 Concrele Pedestal Dimensions: Width_ ti Length ft Thick in 0 Christy Box 0 Stove Pipe PCbIP ❑Submersible 0 Turbine 0 Other _ HP__ Pump Set A Standing Water Level it WELL DESTRUCTION C3 Open Bottom 0 Gravel Pack L Uncased 0 Other W ell Diameter_in Tota)Depth fl Depth to Water fl 0 Casing to be Perforated from fl to d Sealing Malerial 0 Neat Cement(94 1b Ixzg/3-10gal water) 0 Sand Cement sack mix/7 gal water Bentonite Pellets 3011, CU 1tT O Bentonite(20e/solids) O Manufacturer Spec%solids__% Name 0 Spas on •le Cl Specs Submitted Placement Method 0 Pumped 0 Free Fall 0 Olhcr__ 0 Complete with Mushroom Cap A below grade 0 Complete to Existing Surface Pad I . 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM 1,14 COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. n N MUM 'NCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)951-7697 j SIGNED TITLESi7�FF L � DATE.CL E Bunio lLnwl t )mctlenman Rdy - i' f �JAIIA IKap t7r IY� o. Z L) �` rV c rsp Rahroad N r` N C OJVTY cn UB IC EA b, fT yENV Ding 5t I� wa 10 � Z I E;&argent Rd q z bEPARTMEN�USE )NLN Application Accepted By Date Area j� 1/ Employee IDN Grout Inspection By Date CJ JPECIAL Well Permit �{ q Pump Inspection By Date ❑ WAIVER Received Destruction Inspection B Date Gam//[�T- Constructed Well Depth __Tt COMMENTS PE SC Received Ch - Arrwunt Pe m ! InvolceN well IDM' e Service R uesl N Codes Into Rv ('ash Remitted