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WELL/PUMP PERMIT <br /> SAN JOAQLL%COUNTY EM'IRONMENTAL REAL]It DEPARTMENT 600 EA%T Atu.\STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES�I YEAR FROM DATE ISSUED <br /> ^/I <br /> JOIl ADDRL55C(1j'7���2.IP 74151,V\l l J W �_Q_��V' ✓ j <br /> CROSSSTRELT {T— _ APN_� PARCEL SIZE <br /> Ow'NER NAME LkQ'ik-02k4l: TD L� .El PItO%E _ <br /> ONNER ADDRESSR10 O l nLII�Litf,lrF,�l CA::- CFFY/STATLLIP <br /> CON'IRACIOR jaiy- tJc1? 511 J/1 _ x.t 1' t�)�/ Pilo.'E <br /> CON TRACTOR ADORE55Lj1i• �_ _._ Clll'/STATEZP <br /> SUBCONTRACTOR PRONE <br /> SL BCONTRACTOR ADDRESS Cl(l/SI A I'!l'LIP _ <br /> LICENSE OC-57 001 0D-09 cr NLMBER E%P1R.\TIOND.,lTE I" I�� <br /> GEOGRAPHICALINFO .1110%: Coordinates X _ Y _ <br /> Township_ Range Section <br /> LNTEN13ED USE Domestic/Privwc O lrrigationlAgricultural 0Industnal 0 Water Quality Monitoring O Soil Sampiing'Chareeterrzation <br /> 0 Public Water System <br /> Da�R�:a+erm� <br /> Tl'PE OF WORK [IN w WCII 0 Replacement Well O Well AlteratiorvModiftation 0 Test Hole 0 Other <br /> O Monitoring Well(s) ❑Soil Borin �u,on.,or n„im;. aumx.ornm�yr <br /> gts) D Geotechnical _ <br /> 0 Well D"ruction 0 OutofScTviec Well 0 Out-Of-Sen icc Well Rencu-31 <br /> NK_.'cw Pump Replacement O Pump R: it ❑Cross-ConDcction Repair <br /> WLLL CONSTRLC ION <br /> Drilling Method 0 Mud Rotary O Air Roury 0 Auger 0 Cable Tool 0 Push Point 0 Other_ <br /> Proposed Well Depth R Excavation in diameter O Open Bottom O Gnvcl Pack i Gravel Sim__in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GaugxiASTM Sehcd 0 Stecl 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 11 O Nat Cement 041b bag/S-10gal%oter) 0 Sand Cement wck mir,:7 gal water <br /> O Bentonite(201.4 solids) 0 Manufacturer Spec%solidc , Nams 0 Specs on File 0 Specs Submitted <br /> Groat Placement Method 0 Pumped 0 Free Fall 0 Other__ 0 Retardant:Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: Width it Length_11 Thick in O Christy Boa O Stove Pipe <br /> PUMP bmersible ❑Turbine ❑Other HP Pump Set�&)_ft Standing Waier Lcvci _it <br /> N 0n Bosom 0 Gravel Pack 0 Uneased 0 Other <br /> Well DumcWr in Total Depth?_t�4_ft Depth to Water ft 0 Casing to be Performed from__ti to it <br /> Seating Material 0 New Cement(94 16 bag,5-10ga/uurer) 0 Sand Cement .sack mir:'7 gal water 0 Bentonite Pelleis <br /> 0 Bentonite(201/6 solids) 0 Manufacturer Spcc 9i solids__ o Name0 Specs on File ❑Specs Submin:d <br /> Placement Methud 0 Pumped 0 Free Fall Other <br /> 0 Complete with 0 Mushroom Cap _ft below grade 0 Complete to Existing Surface Pad /J �`c <br /> CF/VES <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT'TRE WORK WILL BE DONE IN ACCORDANCE WITH SAN IN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS.AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS f <br /> CURRENT A ACTIV TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AVD THAT I AM IN COMPLIANCE WITH ALL '14 �O/S <br /> woRlaRs H f p U <br /> C E NUTIC F RF I IRED iSPEi T10_N SOF 4 ti <br /> TITLE Y f DATE <br /> �Ikj <br /> y� <br /> --44 it I] <br /> �( <br /> 1 DEPARTMENT U ON <br /> Application Acsxp[od B _ 41 Date Area Employm ION 0 <br /> Grout Inspection By ) 7 i Date ❑ S A ell Permit <br /> Pump Inrpecti �_v - Date_ ❑ WAIVER Received <br /> Destruction Inspection By Dat, Constructed Well Depth h <br /> COMMENTS <br /> PE Sc Rece ted _ Amount Date Pft-MW Invoice N Wen HAY <br /> Codes Into Service Request tY <br /> 10b 165V -7 <br /> I ` <br /> EHD 43-02.006 WEB well Perms andDtt'aracvndoc <br /> 9/11/2007 <br />