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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N 10069 CROCKER ROAD STOCKTON / 95206 m JOB ADDRESS _. ......._....._ CITYIZIP _._...___ 9 _-.._....._ ._._.......__. ...---'---.._... _.... ... _......_ D .._.--------------- --- CROSS STREETHOWARD ROAD _ ..,APN-162 a0J0-02_.....,,,,,, PARCEL SIZE 187.89 Ac.LAND USE APPLICATION -_____-_-______._____.__.._._._. A m OWNER NAME RUDY M. MUSSI INVESTMENT, L.P. PHONE �n -- --- _ OWNER ADDRESS 3580 MULLE. _._... ............. _ CONTRACTOR .J�S�iV1 _W e.� 9 N. _J OPP. _^ PHON � E _ n CONTRACTOR ADDRESS_ _ J-J_Q M 4_G0 3 CITY/STATE/ZIP-.---- ��t c ac>,DO—6 l n X SUBCONTRACTOR m ..._- .............. PHONE PHONE..--'---'----- A SUBCONTRACTOR ADDRESS _ CITYISTATE/LP _—_______________________-__--_--_ LICENSE C-57 � C-61 D-09 Other ____ _____ NUMBER E%_P_I_ATIO—N_D_A_T_E_—___- _ �� 1_ Z� GEOGRAPHICAL INFORMATION: COOrdinates X__6$09017 Y_-2142907-_-_ --- Township-11S.- Range-5E--- Section 1 -Z - INTENDED USE Domestic/Private I Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization r 0.1 c.7 Public Water System _ --_ }r' tZ If diflerent from Owner. --�ireystem flame --�ntacl�lame ar PFone-Number (J) .�. TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other #of bonogs #of borings Monitoring Well(i) #of wells Soil Boring(s) Geotechnical ro Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair -M New Pump Pump Replacement Pump Repair Raise Well Casing X (1> WELL CONSTRUCTION Lj CD fa3 f Drilling Method Mud R tary Air Rotary Auger Cable Tool Push Point Other v > Q- % Proposed Well De pth__��QQft Excavation in diameter Open Bottom Gravel Pack/Gravel Size-.- ,,.,p_, j / n diame Conductnrr Casing—m-LL__in diameter / Cond ptortC�asing Depth fl ■ A Well Casing Diameter IlAn Thickness/Gauge/ASTM Sched bYG Steel Plastic T Stainless Steel) Other_ __tA CM O Grout Seal Depth_ __-ft Neat Cement(94 to bag/5-10 gal water) Sand Cement.....__..._��?____-_sack mix17 gal wa E C Bentonite(20%solids) Other -I.-. Grout Placement Method Pumped Z Free Fall Other Retardant/Accelerator � 1� PEDESTAL Installed Installed By Driller Pump Contractor Other j T Concrete Pedestal Dimensions:Width it Length ft Thick in Christy Box Stove Pipe t C7 PUMP Submersible Turbine Other HP Pump Set It Standing Water Level I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUA'� O A6 CE REQUIRED FOR INV/$J;/IECTIO�[1J`S/I-�PLEASE CALL(209)9!A 7 9/7 SIGNED-------n\ TITLE------Yr`� `'VVi DATE._....._1V {o S P POS DEPARTMENT USE 0IN LY / it�'O�t p ?end y p t _ Date� ' _ Area-,A � :5� Employee ID# t,t�t£p6� � & �1 te—_ SPECIAL Well Permit PAYMENT a RECEIVED Pu p Inspection B �t i•'QI I I�ia1L _L/IYiOfVl lDate ._ _.. ._. ConstructedDate IVER DRP hewed sb�n��I��S�._. .___�...-h-----.-._`-TV--I--`--5--_,I " MAR 17 2015 COMMENTS------------- -- -- ----------------'------- ......._ - - -- SAN JOAQUIN COUNTY PE SC Received Check#/ Amount Permitl ENVIRONMENTAL Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# -IEALTH DEPARTMENT A%q ( {SP, 3 Q-M71 EHD 43.06 /9e� _1 �D !� wELLIPU- U30112 JOB. N0. 2015-24 -1 24 1 1-1