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V4 1 lti_.. .�,I l WELL / PUMP PERMIT. f SIAN JOAQUIN COUNTY]ENVIRONMENTAL HEALTH DEPARTMENT 304,E VEBER AVE awn FL-STOCKTON CA 95202 - (209)468-3420 i NON-REFUNDABLE.PERMIT CALL 209 953-7697 FOR INSPE •TIONS EXPIRES I YEAR FROM DATE ISSUED I `U JOB ADDRESS CITYIZIP 44 71 I'r}0 CROSS STREET OF 1, APN Jg/-;2O`DYii*M.4W PARCELSIZE OWNER NAME. t}LICE M,D�wr/'l.E-12� n7) �7,,,/ PHONE �i ^� �y OWNER ADDRES� 12375 1W a Qo a jead� �' �^ CITYI.STATEIZJP �[�IWA) L� 9 5 ] CONTRACTOR —Fkre 0 lye, ~ /P Dr PHONE 1�^ T �D� CONTRACTOR ADDRESS 6 3/ . AnAwm ec le�j1e(yF_ I so I:jg 1�too CITY/STATE1ZIP fC� €U t CIF 9']D/76 SUBCONTRACTOR R!t.w A'F0 Ee6(k)1 e E`1 API al U6,W C, PHONE li^f5�j�T-3 SUBCONTRACTOR ADDRESS-1112 V. M ITV nfF CITY/STATE/Zip��IA�7E� - ell ` 6 3 3� LICENSE 9C-57 ❑C-61 ❑D-09 ❑Other NUMBER 6 V5 3 / EXPIRATION DATE. GEOGRAPHICALINFORMATION: Caordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agicultural Cl Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water System T If different fmmOwner: Waber SYSTern Name ontact ame ofPhone Number TYPE OF WORK ❑New Well ❑Rcplarement Well ❑Well Alteration/Modification ❑Test Hole ❑Other Monitoring Well(s) �f- number or wells ❑Soil Boring(s) numberofborings ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pum Repair ❑Cross-Connertion Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth J I]� ft Excavation. $ in diameter O Open Bottom &Gravel Pack/Gravel Size- -T in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft Well Casing Diameter 2- in Thickness/Gauge/ASTN1 Sched A;to ❑Steel )1 Plastic ❑Stainless Steel ❑Other Grout Seal Depth a 10 33 tt Neat Cement(94 Ih hug/5-10 gat water) ❑Sand Cement sack mix!7 gal water Rh Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ` ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped 0 Free Fall ❑Other_ ❑Retardant/Accelerator(name) PEDESTAL Installed By I(Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width it Length ft Thick in ❑Christy Box ,Stove Pipe PUMP Q Submersible ❑Turbine ❑Other HP_ Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack L Uncased ❑Other Well Diameter in Total Depth fit Depth to Water ft ❑Casing to be Perforated From tt to R Sealing Material ❑Neat Cement(941$hug l5-ID gal water) ❑Sand Cement sock mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) E7 Manufacturer Spec°/u 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 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 REGULAT►ONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICEiNSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN UM 24 R ADV�ANCE NOTICE REQUIRED FOR INSS�CPr,ECTIONS-PLEASE CALL(209)953-7697 SIGNED f.f 6 TITLE Po ✓r FRZAY-11 DATE �CE WI ER PRERTY MW-j'qVIL t I L Lei L -.3 �� 9f t r DEPARTMENT IISE NIL ! qqApplication Accepted By date �r� I/ Area �1.(� Employez:ID# 1 Grout Inspection By [ Date�[�11 � _ ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received d/ I+! Destruction Inspection By Date Constructed Well Depth— I& ft f� r r COMMENTS Eiji "'- i'lj � Il�l v��ft -tee PE SC Received Check#/ ' Amount Date Invoice# Well ID# Codes Inro B. Cash Remitted Service Re uest EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002