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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 34"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �t IV C[TY/ZIP �jr/G- f APN r] a CROSS STREET + (M 7 v%`} !�] v o PARCEL SIZ O LAND USE APPLICATION# OWNER NAME [A 7/G.+ l Imo(/� �r+ - PHONE "`-' OWNER ADDRESS CITYISTATEIZIP �/C CONTRACTOR �PHONE ` ,.r CONTRACTOR ADDRESS CITYISTATE/ZIP' �/�-7[/ 1Ilq � SUBCONTRACTORl� PHONE SUBCONTRACTOR ADDRESS ' �- CITYISTATEIZIP ' LICENSE 57 W-61 ..❑D-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 If different from Owner: Water System Name R fi j nta a j ne um er I TYPE OF WORK CJ New Well ❑Replacement Well ❑Well Alteration/Modifte tion — rb �� le ❑ #of borin�s t L �' #-of borings (� ❑Monitoring Wells) #of wells ❑Soil Boring(s) ,# ❑Geotechnical ❑Well Destruction :1 �ut-Of-Service Well rm®l u -3edi icl ❑New Pum - ❑Pump Replacement ❑Pump Repair s i WELL CONSTRUCTION1 Drilling Method ❑Mud Rotary i❑Air Rotary' ❑Auger ❑Cable Toolby I'mk-@l r1'st)int _aj ji h Dh .;loll 13 Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casingr in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sea] Depth ft El Neat Cement(94 th hag/5-10 gal water) r ❑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) a PEDESTAL Installed By p ❑Driller ❑Pump Contractor - ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine - 0 Other HP r Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other t 11 Total h epth to ft Ca erf, ted S in aterial Neat a Ib b -10 1 ware ❑Sand ent mix 1 gal wat BR s Ben /o soli ) fa rer Sp o solids o e, pe itte Placeme Method Pum Fr Fal Othero Tete with s om p ft low grade ❑Co e o Existing 5 ace 1 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSA ON S i �HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE �I�-w DATE 1 YA F 4.. - 1 _ l 7 rry ME Aq rmr t ti EPARTMENT USE NLY / 1 _ Application Accepted By «DaterArea1 r Employee,ID# ' Grout Inspection By Date ❑ SPECIAL Well Permit Pump inspection By Date ❑ WAIVER Received t Destruetion Inspection By Date Constructed Well Depth It COMMENTS PE SC Received Chcck#/ Amount Permit/ 1 Invoice# Well ID# Codes Info B ash Remitted at Service Request# F7 c3c�kV 160 ,. 4 �. I EHE 43.02-006 MASTER WATER WELL PERMIT 12122/2003 - �;