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WELL / PUMP PERMIT SAN JOAQI)IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCXTON CA 95202 - (209)168-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED _ �jS: oQ 1 JOB ADDRESS ��114-e-110 l,(� O j�t cn ZIP1 I��EJ+J�, 953 _ �, ('ROSC tiT REST B `'e-1Iy APN `� I � �� PARCF.LSIZE 38'jJ LAND USE APPLICATION# 7�0 OWNER PNON NAMF. 1J�I �Jd � a>J1 25!ridL- 4417.,1 } OWNER ADDRESS 11�, MrhE? CrrY/STATE/ZIP r-'C]3 CIAq<72,, CONTRACTOR P110NF R CONIAC-TOR ADDRESS L,1 L(am!_ �'Mh CITY/STATE/ZIP Sl'BCONT RACTOR PHONE ScBCONTRACTOR ADDRESS CrTYISTATFI7.IP LICENSE ❑C-57 ❑C-t 1 ❑D-09 ❑Other G-$JLD NUMBER >`T EXPIRATION DATE GEOGRAPHICAL INPORMA'TION: Coordinates X Y Township Rang! Section �} INTENDED Uss. ❑ItngationlAgTicultural O Industrial ❑Water Quality Monitoring 0 Soil SamplinglCharactenzation ❑Public Water System -! trdirr[ ,(mill w'ncf' elcf�ftem "� ffc_- CaR1C umbm TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlterationlModitication ❑Test Hole U.Other ❑Monitoring Well(s) _N orwells ❑Soil Boring(s) A-ofbonrVs ❑Occitechnical., a otbonagx ❑Well Destruction ❑Out-0f-Service Well ❑Out-OI'-Service Well Renewal ❑New Pump AlTump Re lecement O Pump Repair ❑Cross-Connoction Repair WELL CON5rRt:CTtoV Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other _ Proposed Well Depth ft Excavatien in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter ' Conductor Casing Depth ft Well Well Cating Diameter in Thickness/Gauge/ASPM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth_ —. _ft El Neat Cement X91 lh hag/S-/0 gal water) C uc Sand Cement sk mcz l 7 gal water ❑l3entonite(2(lt/o solids) ❑Manufacturer Specie solids " :dame _ 0 Specs on File ❑Specs Submitted — r Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) 4- PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Othcr ❑Concrete Pedestal Dimensions: Width R Length ft Thick i in ❑Christy Box ❑Stave Pipe PUMP Submersible ❑Turbine ❑Other_ _ _ HP I _ Pump Sct20L ft Standing Water Level fl Jk-� WELL DESTRUCTION O Open Bottom ❑Gravel Pack 0 Uncased ❑Other _ Well Diametet in Total Depth _ ft Depf.i to Wa:er ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94/h brig/5-10 gal wafer) ❑Sand Cement _sack mir i 7 gal water 0 Bentonite Pellets ❑Bentonite(20"/o solids) ❑.1Janutacturcr Spc.c%solids__-% Name ❑Specs on File ❑Specs Submitted Placement Method 13 Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap_. _ Il below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFI' THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE NVITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RALES AND REGULA770NS. 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, MINI M U HOU ADVANCE NOTICE REQU'RFDEQR INSPECTIONS $ICNE TrrLE ATE ET T b� i DEPARTMENT USE ONLY V y, Application Accepted By_ -C - Dc fr t Area Z� p Err,oloyce ID#� ✓� Grout Inspection Py_ Date ❑ SPECIAL Well Permit Pump Inspection By Dare /� Q. 0 ❑ WAIVER Received Destruction Inspection By_ _ Date _ Constructed Well Depth n COMMENTS_ PE SC Received <fttmlAmount Permit/ Codex Info 13 as Remitted Date Service Request it Invoke# Well ILW I oSZ D f al 6104 5 42o In END 43-02-006 MASTER WAITER WELL PERMIT I V22,7W3