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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED CITY/ZIP a JOB ADDRESS 1 A >�4n�t,��I�� CROSS STREET Dj-Q I'S J2O4 d _APN a 5"'—+ PARCEL SIZE BLAND USE APPLICATION# F1` -N 1 - OWNER NAME I� �27,�11 �cl P�qvrOWNER ADDRESS �!CITYISTATEIZIPT CONTRACTOR -441 12C JDPHONE ��Q �`��j CONTRACTOR ADDRESS O I� eroion. CITYISTATE/ZIP /\aSQf%/rte°I C47 7? SUBCONTRACTOR I� PHONE SUBCONTRACTOR ADDRESS �p CI>T*0 EXPIRATION LICENSE' .- C-S7 11 C 5l: {L❑D-09 ❑Other NUMBER oa EXPIRATION DAT£ 3 �S GEOGRAPHICAL INFORMATION: ° Coo dinatii- X i Y - Township Range Section INTENDED USE ❑Domestic/private ❑Irrigation/Agricultural Q Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water System If different from Owner: a[er ystem amen e a r n II' TYPE OF WORK ❑New Well 17 Replacement Well ❑Well Alteration/Modif[catio T ttqJle ❑ I #of borings ❑ # f borings ❑Monitoring Wells) #of wells ❑Soil Borings) ❑Well Destruction 1I: ❑Out-Of-Service Wel] 'Q [�lt[)t-Srviceeeri�wal ❑New Pum Q Pump Replacement ❑Pump Repair mo or inspected WELL CONSTRUCTION `� ¢i� & Uealth Div-'Ion Drilling Method ❑Mud Rotary I ❑Air Rotary Auger ❑Cable Tool ❑=P�4d 4'tii�t3 D h Pro posed Well D th I! F ft Excavation in diameter ❑Open Bottom ❑Gravel Pack i Gravel Size in diameter p ep ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic D Stainless Steel ❑Other �. sack mix 17 al water t Grout Seal Depth ft ❑Neat Cement(94!h hag/5-!0 ga!wader) EI Sand Cement g 'V ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted 'I' ❑Retardant 1 Accelerator name) Grout Placement Method ❑Pumped ❑Free Fall 11 Other PEDESTAL Installed By i� ❑Driller ❑Pump Contractor ❑Other' 13Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe PUMP ❑Submersible �I ❑Turbine 11 Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom } ❑Gravel Pack ❑Uncased ❑Other Well na I� Tot pthT Dcpth ft Pe rat " al Material ❑Ne e.1 4!h 5- ga ❑San ement k mi 7 gal w r entonite Ile B on 0%s d nu tuolids ame S mit a Place thud ❑Pu ❑ e FtherComplete wi us too Cap w grade ❑ e to Existing rfa 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 WORKERS COMPENSATION LAWS. ' MINIMUM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS r SIGNED / _ / Y „._.:TITLE,.... _ __/Q4�S7' .•.s�= -.t. DAT_E LEAF AAAu vMm n s l ZLam i. Taw - SITE MAP r I q II I { I .S�.P.14. 103 2 1 I P cr,-N ' l( 240� EI 11 ._.. W Application Accepted By T M1Date — tl. = = rts„, rea = 00� s Employee_ID# Grout Inspection By �� Datc SANpII[ell Permit Pump Inspection By ! Date H�1�WVAIVER Received Destruction Inspection By I Date Constructed Well Depth It COMMENTS .r PE SC Received eck#1 Amount Date Permit/ Invoice# Well ID# Codes Info B cash Remitted t Service Request# •erD OWN 5�9_o103,17_uo MASTER WATER WELL PERMIT EHD 43-02.001+ 12122/2003 -