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/ D- WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT�EPARTMENT 304E WEBwlAVE 340 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Lb Al 9 S7icl�� 9Say -z JOB ADDRESS /I CITY/ZIP Y CROSS STREET 1/ VY/✓4"yl F(Pj}(_,APN,/ D� /-03�"��O _ PARCEL SIZE O•S% LAND USE APPLICATION ##9 OWNER NAME S/JJ 'J�,/1 , IrJQahX 1,� (.:ill n4 S,:, j(j nPHONE �! " 931-&101 OWNER ADDRESS 45*51e A 141)r7V�/T� CITY/STATE/ZIP Jy� C-4 p9 27 Z CONTRACTOR �q/el�) r G'rfr,J�t_'I�— PHONE CONTRACTOR ADDRESS eC��` 'r44e 4 17/�e St CITY/STATFJZIP SUBCONTRACTOR �C9�/'IY PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP A LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER 722S'A EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring OFSoil Sampling/Chameterization ❑Public Water System IfdiHeremfmm Owner. water System Name er=as Name or Phma,N.Irbar TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #.fW,ings Geotechnical ❑Well Destruction ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary O Air Rotary WCAuger Cl Cable Tool ❑Push Point ❑Other Proposed Well Depth /O ft ExcavationV, Kin 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 ft ❑Neat Cement(94 Ib hog/5-10 gal water) ❑Sand Cem t sack mix/7 gal water ❑Bentonite(20%solids) 13 Manufacturer Spec%solids % Name �� r.✓us. ,W pecs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/ ccelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 0 Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Unused ❑Other , Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to it Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal water) 0 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 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 IN COMPLIANCE WITH ALL WORKERS COM ENSATION LAWS. MINNH�Os UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED s! TITLE DATE It r\ .41 ; �3AF JCAQ I TTE TT DEPARTMENT USE NL Li Application Accepted By Date 6 a3G C Area —I/ Employee ID# 15i If 4 RC� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection/By M-r /�Q/°i / Date ?41z* / Constructed Well Depth / it COMMENTS PE SC Received Chec Amount Date Permitl Invoice# Well ID# Codes I Info By ash emitted Service Request# 43.7241 ,50 EHD 43.02 O MASTER WATER WELL PERMIT 122nW3