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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE Sas FL-STOCKTON CA 95202 -(204)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jon ADDRESS O*X'ey Cm/ZIP _ ^ CROSS STREET a APN 0 5-a 3a - c-t '7 PA/R�C`EL,SITE I lo OWNERNAME —Flla aeQCA.O�C�Q PHONE �'Y3�70Z IS?i OWNERADDRESS .q5�� CITY/STATE/ZIP A) \ I" CONTRACTOR ) �J /'},. /f/ fJr/ PHONE 20?—?Y-C-2 727 CONTRACTOR ADDRESS_IOD 6;G -,82 �AV ,Y 4 XI/ CITY/STATE/ZIP 2�d&-4W– C>0 SUBCONTRACTOR_ PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE ❑C-57 ❑Cfil ❑D-09 []Other— NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township,_,_ Range Section C INTENDED USE ❑Domestic/Private ❑Irrigalion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterimtion -riG ❑Public Water SyStern I" !rdiff irremOwner• a—system ameomu:i Prmor nc u r L� TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other I ❑Monitoring Wells) numberorwells ❑Soil Boring(s) numberalbori%s ❑Geotechnicxi -mberarbannlp ❑Well Destruction ❑Out-Of-Service Well ❑ E-Of-Service Well Renewal C3 New Pum ❑Pump Replacement ❑Pum R it Ctoss-Connection Repair WELL CONSTRUCTION 7 Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other eC1 Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter Z ❑Conductor Casing in diameter / Conductor Casing Depth 11 Well Casing Diameter_in Thickness/GaugelASTM Sched ❑Steel ❑Piratic ❑Stainless Steel ❑Other i O Grout Sal Depth ft ❑Neal Cement(941h Lag l J-10gal water) ❑Sand Cement sock mix 17 gel water ! O Bentonite(20Y.solids) ❑Manufactura Spec a/solids_% Name_ ❑Specs on File ❑Specs Submitted Crout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By O Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimenslonl: Width_ it Length_tt Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible 1-1 Turbine ❑Other_ HP Pump Set It Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth 11 Depth to Wal,;r R ❑Casing to be Perforated from 11 to R Ir Sealing Material ❑Neal Cement(94 th hug/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(201%solids) ❑Manufacturer Spec%solids_._*A Name p Specs un File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surlace 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. I 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. //tyt•1 h1U 1 24 HOUR ADVANCE NOTICE REQUIRED _FO1 F INSPEC"I NS ��+ SIGNED/j1 R/ TITLE, wL - Prr •a-'l DATE /C> OZ 011,Ap N rA ^tI t Sg,pti at �� ,,//�� DEPARTMENT USE ONLY Application Accepted By Ww' Date �� -� Area _ Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By 4 Date_16-23-0 L ❑ WAIVER Received Destruction inspection By U 0 Date Constructed Well Depth ft COMMENTS Y-2Z-0nV6 PRof PE I SC Amount ChecWH Received Permit/ Codes Into Remitted By Date S treat# Invoice N WellID,# 7 S 5'0 1 l ( zti' ! 0 I ,w END 41.02.006 MASTER WATER WELL PERMIT 5f1P-002