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WELL/ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"'FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7691 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED J03ADDRESS /'�7 C/W'` I "'yN t'��U _..___—.--[—,� CITYYILip 7 n` o CROSS STREET ------ APN �/•, _ r " ��_ PARCEL SIZE `��e at 9 OWNER NAME tR. Pt10N U QWNER ADORFSjS� _ CIl'Y1S1'ATElLIY CONTRACTOR mi(�S� *�jC V Y PIIONE 3&& 3/39 ^-+ u <<- rvlJ� C�k 4S yo r CONTRACTOR ADDRESS_ I, � CITY/STA1E/Z.IY y � 11 $U6CONTRACCORev.�� PIlgNE_T `` AJ+�(/� - S116C0\TRACTOR ADDAEL'S CI'1-Y/STA'rEIZIP �___- t� 1 LICENSE 11C-57 I&C-6 ❑D-69 ❑Other(!/(�-U� 1 NUMBER /yn 3' EXPIRATION DATE'jif 3 q GEOGRAPHICAL I NFORMATION: Coordinates X_ ___— y______ Township Range Se"i0n I NTEN'DED LSEDomcstidPriale ❑lrrigation/Agriculturml ❑Industrial ❑W'al a Quality Monitoring [I Soil Sampling/Chatacuriialion ❑Public Water System_ Ifdlfferaa I,=Owner. amt y>temame unuct,anum wne nim •r "TYPE OF WORK ❑New We]] ❑R',placemntt Well G Well AlterwionlModificat101) ❑Test Hole ❑Other ....... number of—1 is aurabcr or borings number of b—g, ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical C Well Destruction ❑Out-Of-Service Wet] ❑Oue-0(Service Well Renewal New Pum ❑Pump Replacement ❑Pump Repair Cl Cross-COpnection R,51•it 1 -WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Pnin: ❑Other Proposed Well Depth ft Cxcavution _.__in diameter E3 Open Bottom ❑Gravel Pack 11 Gravel Sizn.___in diameter ❑Conductor Casing_- in diameter / Conductor Casing Depth _It Well Casing Diameter_in ThicknesslGaug&ASTM Schext ❑Steel O Plastic LI Stainless Steel ❑Other Crout Seal Depth _ft M Neat Cement(94 1b bag/5-10 y+u1 water) 0 Sand Cement .rack m&/7 gel water ❑Bentonite(201/.solids) C3Manufacture Spec%solids_% Name O Specs on File ❑Specs Submitted Grout Placement Method ❑Pumpe'd ❑Free Fall 0 Other ❑Retardant I Accelerator(name) _ - PEDESTAL Installed By 0 Dnller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width__ tt Length R Thick in ❑Christy Boz ❑Stove Pipe Pump xSubmersibw D Turbine ❑Other HP Pump Set 44> ft Standing Water Level WELL DESTRUCTION 0 Open Bottom 13 Gravel Pack ElUncasod ❑Other Well Diameter in Total Depth _H Depth to Water K ❑Casing to be Pertorated item_ R to ft Sealing Material ❑Neat Cement(941b bag 15-l0gu/warrr) ❑Sand Cement sack+nix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids__% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other -.------_ ------ D Complete with Mushroom Cap_ ft below grade O 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. 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 COMPENSATION LAWS. MIZN.1UM 24 IJOLA ADVANCE NOTICE REQLURED FOR INSPECTIONS LJ� �i�J i r SIGNED TITLE ATE - n �= d i l" L(. rt I v i I I L56 ft��I C-1^-D I Tli- 1 I ,`(`�; '4finj�*� DEPARTMENT USE ONLY Application Accepted By -;l='�+ __—._ Dale '1 -)-j Area_ Fmhloyee IDii Grout Inspection By ,_�/�^y_,,,y / Date ❑ SPECIAL Well PeVMit Pump Inspection ByE=� +N•� t Date 8 Z_ ❑ WAIVER Received Destruction Inspxtion Byr _ Date Constructed Well Depth Il COMMENTS _ /./-//f?�� _.. G --- PE I SC Amount// ,Chet I Received Date Permit/ -----Invoices WellID4 Codes Info Remitted .ash By Service Re nest it EH D 43-02-006 MASTER WATER WELL PERM I"1" 5nn_aoa