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WELL / PUMP PERMIT . SAN JOAQUIN JIDUNTY f NVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 34u FL-STOCKTON CA 95202 - (209)468-3420 $, 0 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRODATE ISSUED ` r Jos ADURFSS G 1C C1TYIZIP CROS:STREET � lam_/�/Z+�'"�•� i/'lr�dil r�/ APN� �y � PARCEL 512E _per _'� /_)_ OWNER NAME r l�J �" PHONE — IqZv 'n OWNER ADDRESS 2el �'`/�� CITYISTATE/ZIP-5�e � , / ` CONTRACTOR PHONRJ Uja f �i J CONTRACTOR ADDRESS� C. c ��//' 4Jr� �/ CITYISTATE/ZIP SUBCONTRACTOR GL!'AFI_ - [Qj•�Y/T"! PHONE G 4 SUBCONTRACTORADDRES•S CITYISTATEIZIPj LICENSE -57 Q C-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/Characterizaiion ❑Public Water Sy_tem If differem from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well Q Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwelk ❑Soil Boring(s) numberorborings ❑Ceotechnical numberofborings Nell Destruction ❑Out-Or-Service Well ❑Out-Of-Service Well Renewal ❑New PUMP ❑Pum RL�iacemcnt ❑Pump Repair ❑Cross-Connertion Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter Q 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 Seal Depth 11 ❑Neat Cement(94 Ih hag/5-10 gal wcuer) ❑Sand Cement suck mix/7 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 ❑Stave Pipe PUMP ❑Submersible ❑Turbine ❑Other HP— Pump Set ft Standing Water Level ti WELL DESTRUCTION ❑O en Bottom 11 Gravel Pack 11Uncased JffOther �sl l-/A! Well Diameter Min Total Depth 11 Depth to Water (,- Y- ft ❑Casing to be Perforated Prot ft Sealing Material Teat Cement(94 1hlurg/5409a1 sealer) 13 Sand Cement sack mix 17 gal water 11 Bent ile Pellets- ` ❑Bentonite(20%solids) ❑Manufacturer Spec%solids__% ]dame ❑Specs on Fi S ecs Submitted Placement Method 14umped ❑Free Fall ❑Other Complete with Mushroom Cap ftbelow grad:- ❑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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIR �E yD +FFOR INSPECTIONS ��`44T SIGNED TITLE - , DATE Af o lnl IR nLj Pl} LSC , EI5 4R EPARTMENT USE -ONLY Application Accepted By D - Area Employee SB# 4�1 Grout lnspectior.By Dale SPECIAL Well Permit Pump Inspection By Z57 Date ❑ WAIVER Received Destruction Inspection By Date 0 Constructed Well Depth ft COMMENTS PE SC Amount Check#/ Received Date Invoice# Well IDICodes Info Remitted as B ervice Request 1LI� 7 EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002