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I !� V� ``�Y4� 1 -Stry1 �� 4 \ '1YY� I. l lil'/ _ � WELL / PUMP PERMIT 1 ;RAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304 E WEBER AVE 3X"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR I.NSPECTI EXPIRES 1 YEAR FROM DATE ISSUED 447 e JOB ADDRESS M A&7� c, CITY/ZIP, 447I/[`'p � / f JV _ y �,y] CROSS STREET !r n/ff-�� "MA J?0*P APN 14 6. d ti PARCEL SIZE /• O OWNER NAME, A4,f M7 Y (a!( � rr �PGH•ONE �* '(] OWNER ADDRESS 1,2 5-7 Q 4 U CITYISTATE/ZIP r 7C4 LOA, C,- )� �� CONTRACTOR IeNlf I�{J�O��,, yy n _ /��P1H�ONE 7IL�`76 ' �✓� 3 CONTRACTOR ADDRE/�S;r I C�(J/�*F eer '0A[l UCr SGI� /C _ Cil-YIS'I'.A'1'E/zIP If�+Te CJ 1Ztr-. C4 ��'J SUBCONTRACTOR 4AAi 6&7Eejl 11e4Z- I��PrLLr IAye. -- PHONE �OQ'�$q#s�}rG`J3-34 SUBCONTRACTOR ADDRESS rI(f. IUr Ifi ffl 67jejFff z CITY/STATE/ZIP gAV]�'e�ill rl LICENSE SC-57 ❑C-6! ❑D-09 ❑Other NUMBER EXPIRATION DATE �dl3rfa S T GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplingfChardcterizaLion ❑Public Water System wne um If different from Owner: Water System Name Zonlacr7�mc o�P cr \(� TYPE OF WORK ❑New Well ❑Repla:ement Well ❑Well Alteration/Modification ❑Test ilule ❑Other ,1 IS Monitoring Welt(s) _ number aI el Is ❑Soil Boring(s) number of borings ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Ot-Service Well Renewal ❑New Pump ❑Pump Re laeement ❑Pump Repair ❑Cross_-_Connection Repair WELL CONSTRUCTION Drilling Mcl hod ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool D Push Point ❑Other Proposed Well Depth It Excavation 4T in diameter ❑Open Bottom ffGr2vcl Pack/Gravel Size 45 in diameter ❑Conductor Casing in diameter / Conductor Casing Depth __ft Well Casing Diameter X in Thickness/Gauge/ASTM Sched yd ❑Steel 0(Plastic ❑Stainless Steel ❑Other — Grout Seal Depth t7 I& 'S - ft I31�Neat Cement(441h hug/5-10gu1 water) ❑Sand Cement sack mix/7 gal water 3 P,65 Pd Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped LWFFee Fall ❑Other_ ❑Retardant/Accelerator(name) PEDESTAL Installed By Id Driller ❑Pump Contractor O Other $(Concrete Pedestal Dimensions. Width ft Length Cl Thick in ❑Christy Box mrstove Pipe Pump ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level 11 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth _ 11 Depth to Water Ft ❑Casing to be Perforated from ft to It Sealing Material ❑Neal Cement(941h bag/5-10gat Rarer) ❑Sand Cement _sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(201/.solids) ❑Manufacturer Spec%solids _% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap h below grade ❑Complete to Existing Surface Pad I 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 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED Tr1'LE Aeo7&--'7 6-sezg6t 5j 1} DATE G r _ ilk '.r P■rrFrr� r � rw��Si-_�.-r _w+�w� s.i�^ r r � r ia�� , �4 R ALICE WIDY'ER PRgPERTY� 'Ir � ,I - t. ne a. I .� „,_ �° M W M W �,�11 r �• ��F: 1. I I ? �� 99 � PLmpS G qri fi'� � �z I I a r- _ Ilk- H DE I DEPARTMENT USk ON Y _lllfIll•l Application Accepted By Date l� Area Employee ID9 Grout Inspection By Date ❑ SPECIAL Well Permit I�C Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date_ Constructed Well Depth I K1 r it COMMENTS tl fr 5Wti tiDl �d�71�1 PE SC Received C*eck#1_j Amount Date Permit/ Invoice# Well 1D# Codes Info qyz — --Cx-sV Remitted I Service Re uest# r EHD 43-02-006 MASTFR WATER WELL PERMIT 12/6/2002