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I WELL / PUMP PERMIT f 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 INSPEC'TTONS EXPIRES ] YEAR FROM DATE ISSUED JOB ADmtuss / l F fe l - �� CITYIZIP p L� tv CROSS STREET / APN IZAP, PARCEL SIZE , f ✓ P ;n OWNER NAME _�7 1��L '�f` I�-�- ! L PHONE — e-9/9f ) n OWNER ADDRESS Q 141(2-14v7— ,^ CITY/STATE/ZIP # �r A CONTRACTOR - PHONE CONTRACTOR ADDRESS TY/STATE/ZIPTom]rC � � SUBCONTRACTOR_ _ ., iC�� -L�/ PHONE SUBCONTRACTOR ADDRESS / �� /-- - CITYISTATE/ZIP LICENSE -57 -61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System -- IrditYerent from Owner: Water SysteM Name Contact arae or one Number r� TYPE OF WORK Iew Well ❑Replacement Well ❑Wel4 Alteration/Modifiemion ❑Test bole ❑Other number of wellsnumber of borings number of borings ❑Monitoring W,-]I(s) ❑Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal Apkew Pump ❑Pump Replacement ❑Pump Re •it ❑Cross-Connection Repair 5 WELL CONS R CTION Drilling Method,,AZ%4ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth Excavation ! in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched J } ❑Steel lastic ❑StainIess Steel ❑Other Grout Sea[ Depth ti ❑Neat Cement(94 Ih hug/S-10 gal water) ❑Sand Cement ,suck mix/7 gal water ❑Bentonite(20%solids) 101manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted In Grout Placement Method umped ❑Free Fall ❑Other 13Retardant I Accelerator(name) 2 PEDESTAL Installed By ❑Driller Acump Contractor ❑Other 'm' �1 ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stave Pipe D PUMP submersible ❑Turbine ❑Other HP - Pump Set !QC,ft Standing Water Level --10e)--t-ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water fl ❑Casing to be Perforated from— ft to ft Sealing Material ❑Neat Cement(94 lb hub/S-10gu1 wafer) ElSand Cement sack mix/7 gal water ❑Bentonite Peiiets ❑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 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. MINI U �I llR CE NOTICE REQUIRED IaOR INSPECTIONS—PLEASE CALL(209)953-7fi9 ,SIGNED , TITLE DATE 4� � i s 1 dj 117 19 Ain I •i` '1 R „y $11. ( AIAI 1 14-52) O 11T i I AIN fig. V„lQS v DEPARTMENT USE ONLY �y 1 Application Accepted By 7 Az Date `� 0 3 Area 1 Employee 1D4 V 0 (y Grout Inspection By / Date &ZAQ--3- ❑ SPECIAL Well Permit Pump Inspection By (. p �1k'. r Pv �7_�- :. Date J -Z & ❑ WAIVER Received Destruction inspection By Date Constructed Well Depth It COMMENTS PE SC ReceivedCheck# Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# KW34 -725' EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002