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W itElu / rUlvir rr >11LIVI 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI --'RARTMENT 304E WEB' AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT (%LsriCALL 7(20991 9553'x-r1'71697 FOR INSPECTIONS �XyL' APII�RES I YEAR FROM DATE ISSUED JOB ADDRESS 1� �VG</W CA.P /Uls F—l�il.._ CITY121j IAgA J 02643(/ � 7 0 CROSS STREET ` APN 13 - 030 - 5�_ PARCEL SIZE 14` 6/8� tt OWNERNAME PHONE-�A� 7—t-�712 I r OWNER ADDRESS CITY/STATE/ZIP C —' PHONE�E✓/ %�I lL_4 % N C CDNTRAcroR CONTRACTOR ADDRESS CITYISTATE/ZIPI r� 1 U CT.J SUBCONTRACTOR PHONE ^ CI SUBCONTRACTOR ADDRESS ITYISTATF121P J 'J LICENSE -57 C-61 ❑D-09 ❑Other NUMBE r EXPIRATIONDATE O GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE omestic/Private ❑Irrigalion/Agricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization tca ❑Public Water System Vdiffermi from Owner: Wmer System Nam. Con=Nam or rhone Number 0 TYPE OF WORK ❑New Well ❑Replacement Well Cl Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells ❑Soil Boring(s) number ufborings ❑Geotechnical numberufborings ❑Well Destructio 13 Out-Of-Service Well ❑Out-Of-Service Well Renewal E3 New pump um um Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 5 Proposed Well Depth H Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter [b ❑Conductor Casing in diameter / Conductor Casing Depth 0 S Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(941h lung/5-10gal water) ❑Sand Cement suck mar/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids T% Name ❑Specson 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 0 Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP7& Pumpset,142Uft Standing Water Level tl WELLDESTRUCnON ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth it Depth to Water R ❑Casing to be Pertorated from R to R Sealing Material ❑Neat Cement(94 lb hag/J-!0 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%Solids) ❑Manufacturer Spec%solids_% Name ❑Specson File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap tl below grade ❑Complete to Existing Surface Pad 1 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 WORKE S COMPENSATION LAWS. 1 UM 2 HOUR ADVANCE NOTI E RED FOR INSPECTIONS SIGNED AT TITLE a DATE c W. Lit toll: I'l Y VI R0 DEPARTMENT USE ONLY �^a Application Accepted By Date 10 '3 Employee ID# J 1 Grout Inspection By Date ❑ SPECIAL Wq1 Permit s Pump Inspection y _ r . Date A2&0)zoj ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COMMENTS PE SC Amount heck# Received Date Permit/ Invoice# Well IDN Codes Info Remitted ash By Service Request# d Os 0 O13 0 0 EHD43-02-006 MASTER WAl'ER WELL PERMIT 5n/2002