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{ WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LAn I � 1 ' JOB ADDRESS N CITYIZIPI �I i CROSS STREET APN_0 7 [ 0v PARCEL SIZ O LAND USE APPLICATION# A OWNER NAME Y`� ULA 7F� i5 CJ yj/ /y'+('�L�—�—/ { PHONE /—+� 70-"7 OWNERADDRESS I CITY/STATE/ZIP �✓J�t /:� G�/� CONTRACTOR ' PHONE � ! CONTRACTOR ADDRESS _ CITY/STATE/ZIPO� !/I'C SUBCONTRACTOR —� PHONE SUBCONTRACTOR ADDRESS - CITY/STATEIZIP ' i LICENSE 57 -61 [3D 09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System iIf different from owner: ater ystem ame nta a 00pe um er TYPE OF WORK ❑New Well ❑Replacement Well -❑Well AlterationA4odifi tion u '� H le LIS r _ ! 44 of borings #of borings ❑Monitoring Wei](s)! 1 #of wells 0 Sail Boring(s) ❑Geotechnical ❑Well Destruction >7)ut-Of-Service Well Perm (u .�y® iclr�Guill� ❑New Pum ❑Pu�np R lacement ❑Pump Repair s i c WELL CONSTRUCTION f��, Drilling Method El Mud Rotary ❑Air Rotary ❑Auger 11 Cable Tool �J ' )SJ(Ni� P�'ynt Il l ,'j f• n d Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sea] Depth ft ❑Neat Cement(94 Ib bag/5-10 gal wafer) Cl Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By - ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe r Pump ❑Submersible ❑Turbine ❑Other HP $ " Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack 0 Uncased �._ ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lh bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%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 REGULATIONS. 1 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 COMPENSA ONS + "24HOUIR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE DATE 1 t 84 1i A I IN M7 AR Ilk I i I I EPARTMENT USE NLY a -Applicaatyion Aceepted By _ T --Date ,Area � Employee ID# .� _ _ �--� Grout Inspection By � Date + ❑ SPECIAL Well Permit I Wt+»p»p Cnspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS ! ,ZO& PE SC Received Checldl/ Amount at Permit/ Invoice# Well ID# Codes Info B ash Remitted -Service Re quest#: .�3 1 I EHD 43-02-006 MASTER WATER WELL PERMIT 12!22/2003 i