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- WELL 1 PUMP PERMIT SAN JOAQUIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 100REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS W CITYIZIP C� }� C J y CROSS STREET \ l Y��`�R�C� l 4U 1�1 APN {7( -I� I c� PARCEL SIZE l�7 Q GiCXI'S' OWNER NAME �r�.V�� yl�ih�itJv t�` cPHONE c3LJ-l'�9y�Z�G{-9 y OWNERADDRESS y`�'�:`1.c�C`�- ti�tD. V �"�` te- CITYISTATEI`LIP JG�� T 1 `I��11 CONTRACTOR 1 t 1WIT PHONE [ ` � � { LD -c �- y,4� ' CITY/STATEZYCONTRACTOR ADDRESS C��gC�'a[-�"o SUBCONTRACTOR PIIONEIko_ Q �_`Iku'L SUBCONTRACTOR ADDRESS xAq-3 CITY/STATEIZIP(IOS � L^ Co4a'L% 55-9- LICENSE VC-57 ❑C-61 El D-09 ❑Other NUMB£RC-6+ +510 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private D Irrigation/Agricultural ❑Industrial Water�u�a'lit Monitorin 11 Soil Sam lin Characterization ❑Public Water SystemP .. M � EXI �E udi€feW from Owner: Water ystem eme TYPE OF WORK �Tew Well ElRe lacement Well ElWell Alteration/Modificati E a P number of wells �•,F Permit rnay_have-expir4wl u F bpaWlL 'ays M Monitoring Well(s) ❑Soil Boring(s) ` ❑Well Destruction ❑Out-Of-Service Well - ❑New Pum ❑Pump Replacement ❑Pump Repair - WELL CONSTRUCT ION r n1 s 1 RCS P� RM i Drilling Method ❑Mud Rotary ❑Air Rotary WAuger ❑Cable Tool /=rte Proposed Well Depth-�a Excavation � in diameter ❑Open Bottom OI Gravel Pack/Gravel Size�aI in diameter ❑Conductor Casing in diameter' / Conductor Casing Depth —ft � Well Casing Diameter 9-5i. Thickness/Gauge/ASTM Schcd 140 R/V 11Steel 51,11plaslic ❑Stainless Steel ❑Other Grout Seal Depth t� -5�J ft LYf Neat Cement(941b hag/3-10 gal wate)l ❑Sand Cement suck infix l 7 gal water ❑Bentonite(20%solids) EI Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted 4 Grout Placement Method l�Pumped ❑Fee Fall ❑Other ❑Retardant I Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑Other r, ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft 13Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 th hug 15-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(2(°/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted I Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT l 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 REQUIRED FOR INSPECTIONS l �,., SIGNED TITLE Frlul+�'�+f��?fxW DATE bf Oro i7/1 JuIL STU —SAA rN r L ...k IDEPARTLrENT US NLY ApplicationAcceptedB _ _ Area EmploAyee M IDN 14 Grout Inspection By Date U SPECIAL Well Permit Pump Inspection By Daie © WAIVER Received Destruction Inspection By A Date Constructed Well Depth ft I COMM NT E SC Amout R ceiv Permit/ Codes Info Remitted ash I By ate Service Request# Invoice# well ID# P.c�la3�9q END 43-02-006 MASTER WATER WELL.PERMIT 5/7/2002