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Vn WELL / PUMP PERMIT Gk yeXL op�7z� y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DN,,ATMENT 304E WEBER.`�3M° -STOCKTON CA 95102 - (209)468-3420 NON-REFUNDABLE -PERMIT CALL] 209 y953-7766y9�7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS /l/I�tOO ]�S ST �K[T _I (i MON /)L-7YQJ CI�TtY/ZIP 4- oCK TUAJ A—", I'fS �j > CROSSSTREET C. A-12- �, l,'�. I/�I VE- APN / ! /—�O�—Oy�EL SIZE ^ r�`� F OWNER NAME M V �r s'�VK.LT I✓)C/ PHONE OWNER ADDRESS ),, CITY/STATE/ZIP CONTRACTOR 4Et �.,,)J 4J C // PHONE CONTRACTOR ADDRESS � CITY/STATE/ZIP SUBCONTRACTOR -F AJ To t Z yRit-L 1N b PHONE SUBCONTRACTOR ADDRESS pU. goA A(19 CITY/STATE/ZIP N IrA LICENSE C-57 ❑C-61 0 D-09 ❑Other NUMBER6:23n2Z EXPIRATION DATE 30 GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestie/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Slimpling/C aracteppation ❑Public Water System Ifdiffenumfrom Owner. ever ysmm ams oniea ams or one um e TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells 0Soil Boring(s) number of borings . 6cmechnical number of bonngc ❑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 ❑Push Point ❑Other n Proposed Well Depth ft Excavatione:�7 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 Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth tt ❑Neat Cement(94 lb bag/S-10 gal water) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) CKManufacturer Spec%solids_% Name P C24kJ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑Christy Box ❑Stove Pipe l PUMP ❑Submersible ❑Turbine O Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other Well Diameter in Total Depth R Depth to Water ft ❑Casing to be Perforated from ft to R r Sealing Material ❑Neat Cement(941b bag 15-10gal water) ❑Sand Cement sack mix/7 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 I 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 i AM IN COMPLIANCE WITH ALL WORK S COMPENSATION LAWS. INIMU 4ADVANCE NOTICE REQUIRED FOR^�I�NSPECTIONS-PLEASE CALL0(211)93697 SIGNED 11�. TITLE �A4;F E�� DA 25, ED fGLARKADOTA FIG s PLANTATIONS NQ4 ^ rr4- Airu,umnnao`r`iuti G® 0 ®0010 e 0@ ® ® J 6uvaonwxoEaTILI, Application Accepted B t NL N.GL'Z.f1' 1 �.� Date 'l(—� Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump II-nspection By Date ❑ WAIVER Received r(Inspection B Date Z--u-I i Constructed Well Depth H COMMENTS PE SC Received ec Amount Date Permit/ Invoice# Well ID# Codes Info By ash Remitted ff Service Re uest# 1-3-7-1- /50 MASTER WATER WELL PERMIT EH D 43-02-006 12/6/1002