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WELL 1 PUMP PERMIT ��// U n I+ L O P ME SAN JOAQUIN COUNTY ENVIRONHEALTH DEPARTMENT 304 E WEBER Net FL-STOCKTON CA 95202- (209)468-3420 NON-REFUNDABLE PERMIT t .11.L(21)9)453-?697 1-01<ksj'l( I IW- EXPIRES I YEAR FROM DATE ISSUED c 153347 - JOBADDItEss ! � �f+�l%� L4 � CtrvlL[P y CROSS STREET APN / 77100 2—✓ P ARCEELL SIZE �] 6 OWNER NAME `J lA/!c/ PRONE �r&,vQ OWNERADDRESS / , CiTYISTATEILIP/'///I Ir e- CONTRACTOR f 1 r' PHONE Je -J33VW CONTRACTOR ADDRESS J Oc V CITYISTATEI7.IP �>rLT r 9S-3 7888 `14 SUBCONTRACTOR /�• 1)r Yl PHONE ff�� l SUDCONTRACTORADDRESS/0i0 ,:3-4'--• _ CITYISTATFlLiP kk LICENSE 6C-57 0 C-61 0 D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section INTENDED USE 0 Donn sticlPrivale 0 lrrigationlAgricultural ❑Industrial Water Quality Monitoring XSoil Sampling/Characler]zalion 0 Public Water Syystem U'diRemnlrmm Onncr: star ystem amc Contact Now orPhane Nurnoer TYPEOP WORK Q New Well ❑Replacement Well 0 Well Alterat'son/Modi ficafion 0 Test Hole 0 Other 0 Monitoring Wells) nun+.6erof%elts Soil Boring(s)T7 numberurbasiags 0 Geotechnical aunarerarbonags 0 Well Destruction 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑New Pump 0 Pump Replacement 0 Plump Repair 0 Cro/�ss-Connection Re air W ELL CONSTRUC170N [s e 0 0 , 6 �S-3 C a S9 Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 11 Cable Tool 4,v'Push Point 0 Other Proposed Weil Depth 11 -Excavation in diameter 0 Open Bottom 0 Gravel Pack 1 Gravel Size in diameter 0 Conductor Casing in diameter I Conductor Casing Depth B Well Casing Diameter in ThicknesslGaugelASTM Sched 0 Steel ❑Plastic 0 Stainless Steel 0 Other Grant Senl Depth ft 0 Neat Cement(94 1b bag i 5-10gal waler) ❑Sand Cement sack ntix 17 gal water 0 Bentonite(2U%solids) 0 Manufacturer Spec%solids % Name Q Specs on File ❑Specs Submitted Grout Placement Method 0 Pumped 0 Frce Fall 0 Other 0 Retardant I Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑Other 0 Cancrete Pedestal Dimensions: Width 11 Length 1t Thick in O Christy Box 0 Stave Pipe PUtHP ❑Submersible 0 Turbine 0 Other HP Pump Set fl Standing Water Level B WELL DESTRL1"GN 0 Open Bottom 0 Gravel Pack ❑Dncosed 0 Other Web Diameter_in Tata]Depth ft Depth to Water ft ❑Casing to be Perforated from It to 11 Scaling Material 0 Neat Cement(94 1b bag/5-10 gal walrr) 0 Sand Cement sack nrix l7 gal water 0 Bentonite Pellets 0 Bentonite(20%solids) 0 Manufacturer Spec°/solids_% Name 0 Specs on File O Specs Submitted Placement Method 0 Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap R below grade 0 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. 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 eW IV 1 211 UR ADVAN(T NOTICE,REQ1JIRED FOR INSPf;CT IONS �c TITLE d DATE L� ro tt tt� p T1yDEPARTMENT USE ONLY q d C� � Application Accepted By V 1 P+Aral 4.Mr, to nCt4 Date 4181 4- Area Employee IDN 145 Grout Inspection By Date e ❑ SPECIAL Well Perltlit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS + r PE SC Amount hear#! Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash Jay Service Re oast# 35b I S EHD 43-02-006 Master Wamr Well Pennit.doc IV2012003