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:� WELL / PUMP PERMIT + SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE VD FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT II CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED LA c` / 9r�_ �141G7 /� CITY/ZIP � /J > JOB ADDRESS .— i O f !` t't //� CROSS STREET —p/�� AP-N;��Cr[f`/TQ ��G PARCEL SIZE �r � LAND USE APPLICATION f ze OWNER NAME /G/r ry /// a/J� ---- PHONE OWNERADDRESS 7-/ 7 CITY/STATE/ZIP ///rJy �.C_e d �7 � CONTRACTOR I� PHONE i CONTRACTOR ADDRESS II CITYISTATEIZIP SUBCONTRACTOR I� PHONE r II - SUBCONTRACTOR ADDRESS I J CITVISTATE/ZIP pp1 1 LICENSE ❑C-57 13C-61 JI ❑D-04 ❑Other NVM Ex 11 A GEOGRAPHICAL INFORMATION: Coordinates X Y r Township _ Range Section INTENDED USE ❑Domestic/]'riva{e ❑Irrigation/Agricultural ❑Industrial t lTmoMRR xpi it haracterization r ❑Public Water System lAlf]1 k b If different from Owner: Water System Name ' !tlC br ne I ¢ TYPE OF WORK- ❑New Well jl,❑Replacement Well ❑Well Alteration/Modification s 1 t'" I L,I Division it of borings of borings ❑Monitoring Wet i(s) #of wells E)Soil Bofing(s) ❑Geotechnical ❑Well Destruction ut-Of-Service Well '❑Out-Of-Service Well Renewal ! ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION ! 1 Drilling Method ❑Mud Rotary j T❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 1 Proposed Well Depths Y ft, Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter # ❑Conductor Casing in diameter / Conductor Casing Depth ft WellCasing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth i. ft ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%'solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted f Grout Placement Method ❑Pumped ❑Free Fall ❑Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other - ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe I ` PUMP ❑Submersible I ❑Turbine ❑Other HP ' Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased yr ❑Other r W '! n To ep Dept P� t P ora _ e ng Material ❑N Ce (941 / 0 gal w r) ❑Sa Cement ckr entoni ellF ❑ 0% ]i an cturer c%solids Name ❑ e bm ed Plae ent Method ❑ e' ree II ❑Othermpletc shro Ca below grade AFFn ur a 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. 1 ALSO CERTIFY THAT MY,REQUIRED LICENSE IS CURRENT AND ACTIVE WITWTHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERSZENSATION LAWS. 1 1NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNS '- � TITLE /��/l/a�.� - — DATE � V .I r II, dig �4 r li !i41-1 1 L li. rr I! E II I I� 7 I. IN d ) I� li .I DEPARTMENT USXONLY Application Accepted By Dat Area Employee ID# q 1. - DateY -= ='---... .._ ❑ SPECIAL.WeIIPermiY Grout Inspection By Pump Inspection By It Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS Ij PE SC Received �Iec Amount Permit! Codes Info Bv ash Remitted ate Service Request# Invoice# Well ID# i E ID 43-02-006 MASTER WATER WELL PERMIT 12722/2003 - -