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k WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3y"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE P�EIRMIT j CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1-)YEAR FROM DATE ISSUED ��`7� S I*7'� W al 7�n Q5.�c�7 //ryry JOB ADDRESS CITY/ZIP Mrli✓►q �V a t�. r C CROSS STREET i Q1S [7.Q APN 1�'570� Ift� PARCEL SIZEr �LAND USE APPLICATION#CL /�N'1�7- OWNER NAME ',L -_+`LLS rr� � VV I�CeS S (� P NE p0q~z165 5o l �h OWNER ADDRESS r �7`'�IGr Irk- Ar CITY/STATEIZIP �� ✓7 r v CONTRACTOR FaPHONE (16-7,(J[7 T 5ClLo /Q 4 CONTRACTOR ADDRESS /,F30 !!er-10^ JT CITY/STATEIZIP kos e w/lei C4 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE- C-57 ❑C-61 ❑D-09 ❑Other-- NUMBER. TUU'--�y EXPIRATION DATE 3 Z>�S 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 fromOwner: Water ystem Name c._ �xrs a .P n er, TYPE OF WORK ❑New Well . ❑Replacement Well ❑Well Alteration/Modificatio - .)(T&tvjl I I 1 ❑ ❑'Monitoring Well(s) #ofwells ❑Soil Boring(s) #of borings X11 �ys� #�fborings ❑Well Destruction ❑Out-Of-Service Well pe 58Fvieeewal I3U� ❑New Pump 0 Pump Replacement 0 Pump Repairon�v-mm d or inspected WELL CONSTRUCTION - ``;; � Uealth Division Drilling Method CI Mud Rotary ❑Air Rotary Auger ❑Cable Tool yO-P4liht D h Ll 11 I Division V]I Proposed Well Depth qQ ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing' in diameter / Conductor Casing Depth ft �7 Well Casing Diameter in ThickncsslGaugc/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941h hag/5-10 gat water) ❑Sand Cement sack mix 17 gal water i ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted. V Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) rh 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 ❑Neat Cement(94 lb hag/5-10 gat water) ❑Sand Cement sack mix/7 gal water ,Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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 l WORKERS COMPENSATION LAWS. , MINIMUM 24 BOUR ADVANCE NOTICE /SREQUIRED FOR INSPECTIONS f (� SIGNED �TITLE.—,V wr-O_fii�fy �- _DATE- NN /gyp — I ATT ~ x� ��, pIF nMp +M+IYOT[med k� ` II r. I I 11--p�I I ra,o i Z ' i IE+R I I III � I 4 ' SITEMAP� t' I I prm+ I If I 6 IZ R� I ALI Application-Accepted By:. : -�=--�.._-- ,,Date—F- to . eoM� tiEmployee ID# yl��ff .mss- _. v ^:. � �. —.Area QO Grout Inspection By '- Date SA e� , ell Permit Pump Inspection By Date 00""WAIVER Received Destruction Inspection By Date Constructed Well Depth ft ' COMMENTS 5r- C� YW SSS r AAA I ! PE SC Received eck#! Amount Permit) Codes Info B as Remitted Date Invoice# WeBID# � t Service Re Uest# I. 'a � EHD 43-02-OOfi MASTER WATER WELL PERMIT L12/2212003 -