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WELL/PUMP PERMIT \ SAN JOAQmN COUNTY ENYIRONMEATAL HEALTB DEPARTa1ENT 600 EAST MAIN STREET-STOCRTON CA 95M-(2")461.3426 NON-REFUNDABLE PERMIT EX/PIIREES�1 YEAR FRR joM DATE ISSUED • los AD(IRt:ss S�Z(O _K C,49-S, /7a� �-----//-�� -- C rz. 4QP_L t�a C> CROSSSTREET Davis A., 01so qp 3 q _ PARRULSdLE8 , 8'0 e OWNER NAME / /ty,/! /'.��7 �/ `) PHONE/�` /` • •'`r/ OWNER ADDRESS Z;qILI (/L� /✓ l[� + C!'1'Yl$fATP//JQCONTRACTO87 /`- CONTRACI'ORADDREss U(U L/W ZCY CITYISTATi/Lr �7z i S�/�-f%',V✓ 9SZ✓�+ SUBCONTRACTOR PRONE SUBCONTRACTOR ADDRESS CRYlSTATFrZtr _ Aw LrtENSE ❑C-57 XC-61 ❑IHN ❑Other NUMBER EXPIRATION DATE GEOGRAPHICALINFORMATB)N: Coordinates X Y_ Town nip Range Sectba INTENDED USE ❑DOnRstic/Privatc 1nigatiodAgriculttaal 13Industrial ❑Water Quality Monitoring ❑Soil SWRAMgKbwaGervetion ❑PublicWatcr .—- ----------------- �/) HddT=at fwmSysWater system tame Caorst N—a Pb—Numbs A A, TYPE OF WORK ❑New Well .Replaccmcnt Well ❑Well AltcratiwJModificalion ❑Test Hole ❑Other_ �� V N T ❑Monitoring Wells) nwobcr ofwdls E3 Suit Borings) n-Awofboriults ❑Ocotec(mical aumbcof Ixru,g� e/ /�D ❑Well Desttuclion ❑Out-Of-Service Well ❑OW-0f-Stavice Well Renewal /�� e ❑New Po Pum R 13lacement it ❑Crow-Connection R A Repair _ 1 Drilf" WELL ethod NSTRUCTION SqN / ZO?0 Drillag M ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push q Point ❑ uer _ JO Proposed Well Depth ft Excavation in diameter ❑ n Bottom ❑Gravel Pack/Gavel Size / QU/ `. ❑Conductor Casing _in diameter / Conductor casing Depth - It R n 4L.�fv ry Well Caslag Diameter__in Thickncss/CraugeJASTM Sched ❑Sleel ❑Plastic ❑Stainless Steel ❑Other A R T Groat Seal Depth ft 0NeatCement(941bbag/5-10goI%Wer) ❑Sand Cement =wcAmLr17galwater n/]' ❑Bentonite(201/.solids) ❑Manufacturer Spec%solids__% Namc_ ❑specs ortPik ❑Specs Submitted Groat Placement Method ❑P ❑Frec Fall ❑Otho ❑Retards/Aar(name) PEDESTAL (alto d By ❑Driller ❑Pomp cenhactor ❑Other __ ❑Concrete Pedesw Dimendeft: Width_R Lengtb ft TIUck in ❑CWW Baa ❑Stave IPlpe PUMP 'bio -rurbinc ❑Other HP Pump Set ft Standing W-W Level it WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uw4sed ❑Other Well Diameter-__in ToW Depth ft Depth to Watcr ft ❑Casing w be Perforated from__.ft to It Sealing Material ❑Neat Cement(941h bag/5-10gal anter) ❑Sand Cement. am.•t mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids__% Num __ ❑Spccs on File ❑Specs Submitted Placement Metbed ❑pumped O Free Fall ❑Other. ❑Complete with Mushroom Cap R below grade 13 Complete to Existing Surface Pad I HEREBY CERTIFY THAI'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 AIM IN COMPLIANCE WITH ALL WORKERS COMPENSATION WSS. STONED _ TITLE I I noo at >/ DEPARTMENT U' O. Y Application Accepted Byls- 1� Date 6 O� Area _ Emp!oyclL)4 J ►7�� Grout Inspection By Date ❑ SPECIAL Well Permit f r 1�-r.,,,L > c ❑ WAIVERRecelved Pump Inspection By Y't^csrCsS CO L?wrs-`sa. Destruction Inspection By Date_ Constructed Well Depth ___...ft COMMENTS — PE SC Received CBeetdN Amount Pate Perms IBvakeN Well lDN Codes Info Remitted Service 1 43$1 OSO '7 O EHD 43-02-006 WEB Well Permit and Declarark-doc 9/11/2007