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k .�I&fLL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL ITEALTH DEPAIWT 304 E WEBER AV L - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL. (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED a I .1k _ t 1 . 1 ► A_ 1 .. A I JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS -?O a' , G7 -z I SUBCONTRACTOR APN P PAR��Cy�E�\L SIZE PHONE Q(�J CITY/STATE/ZIP PHONE /► //��/'�ry�,► CITY/STATE/ZIP O!Ma-�^��/]"1-'�J�113 PHONE -t I W oa I -11M SUBCONTRACTOR ADDRESS 5-4* D P-yCzt-L?&-.,/� CITY/STATE/ZIP 5xfo / LICENSE ❑ C-57 ❑ C-61 ❑ D-09 Other bLh -A NUMBER c int 6110 EXPIRATION GEOGRAPHICAL INFORMATION: Coordinates X INTENDED USE Domestic/Private ❑ Irrigation/Agricultural Y ❑ Industrial Township Range Section ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole Other ❑ Monitoring Well(s) 5 number of wells ❑Soil Boring(s) ❑Geotechnical number of borings number o orings ( ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ New Pmmn n Pumn Renlarement n P,, .. Q.—;' rl Do...,:� WELL CONSTRUCTION /U _ _ _ w `I Iv--1(.,,,1D-tQJ,c'I'JI^hl Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ther I � Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 lb bug /5-l0 gal water) ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑,Specs Submitted Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) } PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set tt Standing Water Level ft WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Diameter in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to ft Sealing Material ❑ Neat Cement (94 lb bug /5-10 gal water) ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Complete with Mushroom Cap ft below grade ❑ Complete to Existing Surface Pad 1 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 ZOOZ/S/Z 1 uoilot:.teloaG ioloe.quo0 lnutad 119M .taleM 2I3.LSVW LOO-ZO-£b GHB ;uuallddd 018Q •sasodmd uol;oadsui ion ,4ndoid pauotluauz-anogE au; uodn ia;ua of 14unoo snlI JO sant;s;uosaidaz azuoq;ns Agonq put, `uoiloiu;suoo utolsAs a2vAos io put, uoilomnsuoo IlwA o; 2upulai sMsI a;t,ls pus saausatpz0 ,,4unoo pus ilio IIs g;iM Aldwoo o; aaz2s I •;oa.uoo St uo>;suu03ut anogs 3qj ;sq; als;s pus uoi;soilddu sugj psa.I OAL'q I 11Og; AJPJQa I # ;?UUad Xja3uS I2!4snp1I13o UOtsiA1Q I] •uO1slAtp oq; uzog lioM Bons op of liuuod s ssq uoszad Bons ssalun `anogu palou sr `ApjrS IuTjlsnpul 3o uo►s►AI(j agl uioij ltuuod u a.gnbw pinoM gotgM lioM op o; ouofuu Aoldwo jou IIjM I `japlmq-zauAAo sd (] 13POD 0AIj1?4Stunupd enuOPIUD `8 ai;?Z `Ib£ uoiloaS `Z alotlid `Z dno.z0 `Z.£ n1dsgj) -q$Tq 13a3 (9£) xis-A.ngl uugl wool aq Bion `3oajag1 Su>l;uUWSTp so uOutlouzap Jo `jionnasls3 `2utplgguos `aan;onlis Sutplinq ou ;sq; put, `ltuuad aql Xq pazuoq;nu 3IioM glten u011301uoo ui apuuz og IIiM `puaosap_ �almbaz sI uosiad s goignn o;ut dap ut_ Laa3 azoui zo Gang not;unuoxa Ou ;sq; �i3t�lao �Cgazaq 1 p r a v v en