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WELL / YUIV1Y YEKIVll 1' SAN JOAQUtN COUNTY"-ENVIRONMENTAL HEALTH T' ZTMENT 304 E WEBER/�3aa FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT __ 3ALL 209 953-7697 FOR INSPECTIONS _P1RES I YEAR FROM DATE ISSUED �r` y A ��j�'^ 777 � JO A'tDDRE55 e /V V CITYIZIP��+ Cy J /Z 6C F7 �^- y � 07$cial SS o�S^I � CROSS STREET r APN PARCEL SIZE ) + v OWNER NAME AZ e/l..C e ` - PHON k OWNER ADDRESS /��F'V C[TY/STATEIiGIP t p " CONTRACTOR G 7 Lam✓ � C ' PHONE [�! 3 � CONTRACTOR ADDRESS L C ' ' ` � � �'✓ CITYISTATEIZIP SUBCONTRACTOR +tf �`! � PI10NE�/�� '/0 �-J ^� SUBCONTRACTOR ADDRESS 57"- CITY/STATTEE//Z]IP-- C L (/� ! f LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION. Coordinates X Y Township jLl�_ Ranged Section _ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ater Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Q If different from Owner: Water riystem Narne Centact Name or m TYPE OF WORK ❑New Well ❑Replacement Well "❑Well Alteration/Modification ❑Test Hole ❑OtheislEX Monitoring Well(s) numberofwells ❑Soil Boring(s) numberofborings 13Geotech ((❑__Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal `y ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTIONI Drilling Method ❑Mud Rotary 13Air Rotary �Au er ❑Cable Tool 17 Push Point ❑Other Proposed Well Depth�It Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter" ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter ck_in Thickness/Gauge/ASTM Sched .S`A $0'0 ❑Steel ))'lactic ❑Stainless Steel ❑Other :Grout Seat Depth a'2 tt Meat Cement(941h hag 15-10 gal water) ❑Sand Cement sack mir 17 gal water 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Crout Placement Method Cl Pumped ree Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width tt Length ft Thick in ❑Christy Box tove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft € WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth 11 Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 th hug/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other O Complete with Mushroom Cap t below grade ❑Complete to Existing Surface 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS: MU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE � � J / DATE C/ 5 J i 15 DEPARTMENT USE NLY LFT_-�.ApFjpcasion_AccepBy— —Date _16 d 7r Area _Employee ID# - Grout Inspection Date !U/IL ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed'Well Depth ft COMMENTS./_ ��ty'l. l/a��Io� i/sl D� T�Ad clyeg2e r7' ,r'X1271/ ' PE SC Amount Chec Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002