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re'LA I a Vl'.A ALl SAN JOAQUIN COUNTY ENVIRONMEWAL HEALTH DEPARTMENT 4.304E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)46&3420 NON-REFUNDABLE PERMIT CALL(2091111110-7697 FOR INSPECTIONS EXPIRES I YEAR FROM 9W ISSUED roll 9 JOB ADDRESS CtTY/ZIP 0 CROSSSTREET C_ MQI n cfr.O+ APN 2 611 -15-035 a PARCEL SIZE 0,'/ Q.0 re_ °s OWNER NAME Wi111om a.idlern/ God.nem- PDONE (7-o 1\/ 1 I'-7z6j OWNERADDRE55 c213^A3 PfO�..YC�IICI F�VP1Y-II.I]E.��, ..CLCITY/STATFJZIP ��T o/n,(\'AgpGQ1�S�3^(o(o '`a6GRYA BN+ `J I,IKWGPIyIron/ney-;k1 D' Il��r/h9r r L),C- //-gn.,is A 25)F/0�F- 22�3 CbFiRA�CTORADDRESS`I DOS Pod 0-6 Cil NWNI. CITYISTATEIZIP C o rsco r�iL�F'eC 911/52-0 -9l:12ACTOR O�V-L.' rr, PHONE 14 9BBCONTRACTORADDRFSW I CITYYISlTATFIZIP r L�JA3E�G' eA'J O((]]VLJ LICENSE C-57 0C-61 0D-09 ❑OtherNUMBER 0; EXPIRATION DATE.113 GEOGRAPHICAL INFORMATION: Coardinates X(V30 Cq 1YZvZ '115'T.D.,hip 5 RangeS _ SeelloaJ7q _ INTENDED USE ¢IMmestic/Privale ❑InigetiontAgricultuml ❑In hatmid ❑Water Quality Monitoring ❑Soil Sampling/Characterimtion ❑Public Water 53snor ud,Reunr4om Ownee mer 'nem arae C.x,1Ni—w PW.N—bar TYPEOF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test We ❑Other ❑Monitoring Well(s)_ ...te'orwens ❑Soil Boring(s) naa'berorbodnp ❑Gerechnical nnn,bmo@orinp XWell Destruction ❑Out-Or-Service Well ❑Out-Or-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Crass-Connection Repair WELLCONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gavel Sim in diameter ❑Conductor Casing in diameter / Conductor Casing Depth 11 Well Casing Diameter_in Thicknem/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Sminless Steel ❑Other Grout Sed Depth Il ❑Neat Cement(941A bag/5-/0 gal water) ❑Sand Cement .smkmu/7gilwater ❑Demesne(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specson File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Fra Fell ❑Other ❑Retardant/Accelerator(name) PEDESTAL [.,felled By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ H Length_R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine gOth.r f4ts 0 ill HP_ Pump Set tl Standing Water Level R WELL DESTRUCTION C3 Open Bottom ❑Gavel Pack ❑ .cased �r-� ;(Other n n Well Diameter�in Total Depth 3R A Depth to Water ."rL it ❑Casing.01T be Peribated fm R to R Scull,Material gNcM Cement(94/6 Meg/5-10 gal wafer) E3 Sand Cement vmk rnic/7 gal water ❑Bentonite Pellets O Bentonite(20M,solids) ❑Manufacturer Spec%solids_% Name ❑Specson File ❑Spas Submitted Placement Method (Pumped ❑Fra Fall ❑Other ❑Complete with Mushroom Cap Il below grade XCompicte to Existing Surfae Pad I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M 24 HOUR ADVANCE NOTICE REQUILRED FOR INSPECTIONS SIGNED TITLE /T O DATE a ry i 138 Iff'... 00� r 5 r ca ca 42 DRIVEWAY CA T 233 >s��/��/ IN ■ } DEPARTMENT USE ONLY Application Accepted By '-1M. Date to Ov Ara Employee IDN Grout Inspection By - y Date �< SPECIAL Well Permit Pump Inspection By Date ❑ WAIVERReeeived Destruction Inspection By ✓ �wt7. Date 1'{ 7 O Y Conslrueted W 11 Depth JAI_ft COMMENTS SI DI.rJTLt 11 In7AD/hA�L 50 ef(S$LLfL QfO HII�Uu.1Z0(fps{40Ysg�7L��r,L� PE SC Amount ChakN/ Received Date PermH/ Iinvolcell Well IDN Codes Info Remitted Cuh B Service Ran...If N l(o s o { 8 (00-- Sol EHD43-02-006 MASTER WATER WELL PERMIT 5n/2DQ2