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a e OPY FILE C WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIt DEPARTMENT 304E WEBER AVE 3'n FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED �.riY wryl-Cc✓h rI q L cc.u,Sr�,'pTr k=e;r>• /Sulu' o0sg14/N Ce,," v. JOB ADDRESS D 6• v 12 a•/� 7 I�-T CIT1'/ZII' r' CROSS STREET 7 ,.,/V,�LGC,s.157 1,-eeF-c�,nPN (),I-117-- PARCELSIZE. OWNER NAME `3 C I fly �.4 j.t �Z L G/Q�L F� PHONE(2V \)33+ — 4F7��" K.K. IG 1�1r� l.t Y7 1 / OYYIVERAoDRESS 'S`4"�I L-' �1� --t L��- r'�CAc CITY/STATE/ZII' Cc✓'/t rC/-/7"t't ")S/7Z-1�-1C �y CONTRACTOR NI��1 I [,�• - P^IIONF. Z- I^' r.',�� CONTRAC 0RADDRESS :7 �' f ni'L'1,y -I'�N r(��I AG-1.Ji c. -T�CITY/STATEYLIP _jl�(,I�PILh,Q�.,i�t) SUBCONTRACTOR SPL'C:rr'lllltn CA N1c,�'C- . PRONe1 tet'��•S._ x`773 SUBCONTRACTOR ADDRESS 73 657 1 A sV A I"1�'` CI'rl'/STATE/ZIP S�(�L�C/7 Ct 7 L C.5 LICENSE PC-57 0C-61 0D-09 ❑Other NUM ER LS' -S(2-Z(JB EXPIRATION DATE 3G G'S GEOGRAPRICALINFORNIATION: Coordinates K Y Township_ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial L�AVEtcr Quality Monitoring G.I'Soil Sampling/Characterization ❑Public Water System Irak ,From ihrner .ter Iat ona ontari N--illFon.,un..r TYPE Or WORDow Well ❑Replacement Well' ❑Well Alteration/Modification ❑Test Note ❑Other ❑Monitoring Well(s) ,b—f-16 till` ❑Soil Boring(s) nunsberortn,rings 0 Geotechnical ^^tuber orbonngs ❑Well Destruction ❑Out-Of-Service Well ❑Out-Or--Service Well Renewal O New Pum ❑Pum Re lacemt t ❑Pum Repair ❑Cross-Connection Repair WELL CONsrRUc-I'ION SC! 1�hi Drilling Method O Mud Rotary ❑Air Rotary awoic, ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /Up ft Excavation & in diameter ❑Open Bottom "ravel Pack/Gravel Size IZin diameter ❑Conductor Casing indiameter / Conductor Casing Depth Il 3T—w i-5 Well Casing Diameter 2.t in Thickness/Gauge/ASTM Sched 1K,1 PL16 ❑Steel [39fastic ❑Stainless Steel ❑Other Grout Seal Depth D_51 Il tl� m Ceenl(94/A/u,g 1 J-l0gal—ler) ❑Sand Cement sack rnit/7 gal water ❑Bentonite(20%solids) ❑Manulbcturer Spec%solids_% Name ❑Specs on rile ❑Specs Submitted Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(nmuc) PEDESTAL Installed BY �iller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_It Length_R Thick in ❑Christs'Box P<vc Pipe _ PUSIP ❑Submersible ❑Turbine ❑Other IIP Pump Set It Standing Water Level li WELL DL'.4TRuc-rioN ❑Open Bottom ❑Gravel Pack O Uncased ❑Other Well Diameter in Total Depth B Depth to Water Il ❑Casing to be Perforated from Il to R Scaling Material ❑Neat Cement(941h hug/5-10ga!starer) ❑Sand Cement swek,nix/7 gal water ❑Ilentonile Pellets ❑Bentonite(200/6 solids) ' ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method O Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap 1t 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 WITII 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 LAWS. �7 N71NIMUM 24 IIO)JR ADVANCE NOTICE.REQUIRED 1012 INSPECTIONS SIGNED -(LZsvi/�!-rX 1.7 -7 11- TITLESL,yor wea�Cr,rSY- DATE �J C��4- a �'. uaeY� '_ .L'�,'�s�`Yti;. •.I��7��n�� ir�:' •i -A O -�-r.- _ ..r tT s }R;r-I;Y r t wwl- A9 AI o B i r.ti.A �� I. G•r, x ry,i , • i H �-'� x e s�.s x xl � __J I As g Gro , t r'x -j G Application Accepted By +`JIl;derr TJl�^-�"^-^'°•^�-I sun®„ �. Ino.• ' 'In sr - .. urea L•mplo`yce wq(lOo Grow Inspection By Date ❑ SPECIAL Well Permit Pump Inspeclml By I}ate ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS Codes SC Amount C / oq Received Pei-mill Codes Info emitted Cas.,Jl g B D to Service- l q Invoice q Well IDq l�L EHD 43.02-006 MASTER WATER WELL PERMIT �� snr_ooz