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~ WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Tn <br /> �/ /E lib TYa Cq , Ca. '76-37(e _ " <br /> JOLT ADDR69B L�� (ll.�. CrfY/ZIP > <br /> CROSS STREET [fit 1!!1 r// K/��/�f�s,�.. (� APN -",09 —� 0 r2-3 PAARCEL SI E <br /> OWNER NAME W t,'/+f'Cil NO2--S ,A` <br /> OWNER ADDRESS /�O 00 0i- V�(.I lie,k f�" CITY/STATUZIP <br /> CONTRACTORj2sr <br /> / ,/) ?-7-rl(* <br /> PHONE <br /> CONTRACTORADDRESS Po. 30 1r -Fra ac ' L-(( I '.378 <br /> SUBCONTRACTOR N f PItONE /J aL <br /> SUBCONTRACTOR ADDRESS/I/D- ^ CITY/STATEMP N.e �7 <br /> LICENSE 0C-57 XC-61 ❑ ,yD-09 Ia Other C.f� NUMBER r13993£ EXPIRATIONDATE O //© <br /> CLOCRAMICALINFORMATION: Coordinates X Y Tawnshlp Range Secfioa <br /> INTENDED USE ❑Domestic/Private ❑IrrigatiodAgTicultural ,171 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charscteriaation <br /> O Public Water Syltem <br /> IrdiffffcM from Ower mer yN ame -meet mnem meN—b. <br /> TYPE OF WORK ❑New Well ❑Rcplacemenl Well ❑Well Allcration/ModificaLion ❑Test Hole ❑Other <br /> number ofwrllr t <br /> ❑Monitoring Well(s) ❑Soil Boring -'­Of boring s) ❑Geotechnical numberofborinp <br /> ❑Well Destruction ❑Out-OfService Well ❑Out-0f--Service'Nell Renewal <br /> 11 New Pump ump Rb lacemenl ❑Pump Repair ❑Cross-Connection Repair <br /> WELL.CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cabk Tool ❑Push Poin: O 06rcT <br /> Proposed Well Depth H Excavation _in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diametcr / Conductor Casing Depth _R <br /> Well Casiag Diameter`in Thicknem/GaugeJASTM Schcd ❑Steel ❑Pln.mic ❑Stainless Steel ❑Other <br /> Grout Sed Depth it O Neat Cement(94/h bag/5-10ga/w irr) ❑Sand Cement suck rnix/7 gal water <br /> O Bentonite(20%solids) ❑Manufacturet Spec%solids % Name O Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑PumpW ❑Free Fall ❑Other ❑Revrdant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ It Length ft Thick in ❑Christy Boa O Siwe Pipe <br /> PUMP Submersible ❑Turbine ❑Other_ U HP� ]_ Pump Sct,_a!�afl Standing Water Level it <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water R O Casing to be Pcrforaiod from ft to It <br /> Sealing Material ❑Nat Cement(94/h bug/5-10 gut wtdrr) ❑Sand Cement sack mix/7 gal water ❑Benloni tc Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids___% Name ❑Specs on File O Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other__ <br /> ❑Complete with Mushroom Cap tt below gtadr ❑Compiete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN U11J 2 H'O'U``R ADVANCE NOTICE <br /> /tREQUIRED FOR INSPECTIONS -��7/J� <br /> 31CNEb >Q� TITLE (�((-�/`,.C� DATE / ,../�-" O <br /> fill 11111 11 <br /> ail <br /> tA <br /> OL77 <br /> /v` <br /> DEPARTMENT USE ONLY 1 <br /> Application Accepted By Date /D-07-42. Area t` mployce IDN <br /> Grout Inspection By Date ❑ SPECIAL Permit <br /> Pump Inspection Date !d/JjF��i ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth If <br /> COMMENTS_ <br /> PE SC Amounthe Received Dare lavoicc# We111DA <br /> Codes into Remitted B ervice R t# <br /> 3 <br /> EKE)43-02-006 MASTER WATER WELL PERMIT <br />