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4r WELL/PUMP PERMIT y 9 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3BD FL-STOCKTON CA 95202-(209)468-3420 1` NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED _76JOB ADDRESS IZL W CITY/ZIP LA-f iAtoI' Ann o CROSS STREET L I{R. Seo pN FQ- W IQ7 APN -22 `V PARCEL SIZE OWNERNANX o +f7 G-5 I PHONE —7 OWNERADDRESS o 6ZCITY/STATE/ZIP -rt4 G� CONTRACTOR �p LOW,,y EY A 550 c- a/N S PHorr>i�CI 2 S 27S'Z SSS CONTRACTOR ADDRESS nZ ZSD LAM iµ— �QyNl pnJ CITY/STATE/ZIP -.s 4-V Q ✓ 4^O l Gf} �2t Y5�3 SUBCONTRACTOR IZ�-� �z20T r u,a 1(./}L p PBO�NtE/�( Z0�J 1 Z 3 -34 J,s V SUBCONTRACTOR ADDRESS l I t Z IV, 0-4&&) '5 #�O CITY/STATE/ZIP M/T"'?��'A- C��T' J36 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 62-6S3y EXPIRATION DATE 1301(9-7 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 differwt from Owner: Water Srtem arae Contact Narae a Phone Number TYPE OF WORK: ❑New Well ❑Replacement Well ❑Well Alteration/Modification Test Hole ❑Other ❑Monitoring Well(s) number ofwetls „soil Borings) °1®�r f bO°O Geotechnical -y numter oftwrings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ) Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 1!L�- 5-0,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 Seal Depth I I u''Wf-*ll Neat Cement(94 lb bag 15-10 gal water) ❑Sand Cement_ sack 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 ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material Meat Cement(94 Ib bag 15-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method A—ped ❑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. 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. / / lY ,I 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ! - �^ TITLE 5i.• �/}r%- r�e^i 1Z/2a� _ I �- r 222005 0 `Y,':•��Y-r � �� ,l �^may, vwvoszo 65�-a.v� cot�z.�,,` 1 Application Accepted B f Date Area Employee ID# Grout Inspection By _ Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection BLy ate Constructed Well Dep ft COMMENTS / 7 m G t PE SC Amount lee eceived to Permit/ Invoice# Well ID# Codes Info Remitted Cash B ServicenRe guest# G'V Z EHD 43-02-006 Master Water Well Permit.doc 8/20/2003