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a WELL I PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 F NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED } 1 .: �j ' • 1 L CITYIZIP n r te- JOBADllRES� / {� - _._ c� r - v i �p kk CROSS STREET l� APN C7 C J - ` PARCEL SIZE t�p CnCX'PS' 1 OWNER NAME 6r�t�IC�J��-1t`��' r PHONE OWNER ADDRESS f� 1 CITYISTATEIZIP (C-pr CONTRACTOR 1 ti 11AJ1� �PHONE L1 ��n{n�n(?�1�-1 CONTRACTOR ADDRESS CITYISTATE/ZIP tPHONE SUBCONTRACTOR n,.,,,.,� SUBCONTRACTOR ADDRESS �� CITY/STATE/ZIP LI � I+ LICENSE Q`C-57 ❑C-61 ❑D-09 ❑Other NUMBERC55 { �� EXPIRATION DATE I GEOGRAPHICAL INFORMATION: Coordinates X Y TownshiMp Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial WatertuahtkMorntonn ❑Soil Sampling/Characte-REri❑Public Water SOstemI � �if different from caner: ater ystem ame ! f � TYPE OF WORK W Well „ ❑Replacement Well ❑Well AlterationlModificafi�... � number of wills Permit may have-ex-pir�Y � wrings �Monitoring We'll(s)�_ ❑Soil Boring(s) ft ❑Well Destruction ❑Out-Of-Service Well -�4t�ht t � g�rvtpetd tib rhted- ❑New Pum L❑Pump Replacement _ ❑PuumRepair m� WELLCONSTRUCTION � P r -ACffiSC� -CkN(qp- ,,nk Drilling Method ❑Mud Rotary ❑Air Rotary IXAuger ❑Cable Tool 1�_ __. ...- �,v❑tct� Proposed Well Depth_ oo-,_ft Excavation in diameter ❑Open Bottom I�Grave]Pack/Gravel Size#a in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft SPW� Well Casing Diameter a•Sn Thickness/Ctauge/ASTM Sched _ ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth 0 -65 ft Neat Cement(94 1b hub 15-10 gal water) ❑Sand Cement suck m407 gal water 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted i Grout Placement Method INI Pumped ❑Fee Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By I. Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box kstove Pips PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set. fl Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased- ❑Other Well Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from ft to It i S ria t Al's)(441 g/ 0 ❑S •k i ate Pel Q entonit 0° Ma acturer ec%solids % Nam ❑ ecs on Specs Sub ed Pia ent etho ump Fr all ❑Other ample itki ush C ft below grad Co lete to Existi Sur a Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND A THE WILL BE N N ACC 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 DOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS . F �� 1 ^� SIGNED TITLE t�+{ DATE �I�o I WB Er X 'r i Ik f / I 1 I 2 � M DEPARTMENT US NLY Application Accepted By Date Area Employee ID#�A,I . - ,__f GToui inspection Bq �"� - �"` " " Date' "�' ❑ �Sl' CIAL Well Permit 1 Pump inspection By Date ❑ WAIVER Received Destruction Inspection By 4 Date Constructed Well Depth ft COMMENTS bA A "! PE SC Amount Received ate Permit/ invoice# Well[D# Codes Info Remitted ash I By ip if Service Request# qq . t EHD 43-02-006 MASTER WATER WILL PERMIT 5!712002 .i