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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTYENVIRONMENTALHEALTH DEPARTMENT 304 E WEBER AvE 3""FL-STOCKTON CA 95202 - (209)468-3420 i <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESSCl/T�YI�Z}t�P <br /> d APARCEL 5SIZEPIY/19$1 QtlrL <br /> CROSS STREET r/ G I <br /> tn <br /> OWNER NAME CrI V a!�/OIL �1 '/�' r.f A PIIONE <br /> �} 112C Al� <br /> VOL <br /> OWNER ADDRESS '+ � CITYIATE/ZIP a�A N •►� � � <br /> r <br /> CONTRACTOR PHONE 110 G, <br /> �- <br /> i <br /> CONTRACTOR ADDRESS —300 0 , ,d CITY/STATEIZIP I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C1TY15TATEIZIP <br /> sE C 57 ❑C-61 ❑D-09 ❑Other NUMBER /�/� EXPIRATION DATE �� <br /> LICENSE ; <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section �I <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Wafer ystern ame ontact ame or one um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> number of wells number of borings number of borings <br /> 11 Monitoring Well(s) ❑Soil Borings} 11 Geotechnical <br /> 0 Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump Pump Replacement ❑Pump Repair ❑Cross-Connection Repair 'WELL CONSTRUCTIO <br /> Drilling Method Mud Rotary 13 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Othe'r <br /> Proposed Well Depth-400 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> rM-�Ia ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lh hag/S-10 gal water) ❑Sand Cement suck mix 17 gal water '-N <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in E3Christy Box ❑Stave Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom <br /> [3 Gravel Pack ❑Uncased 11 Other <br /> Well Diameter�in Total Depth ft Depth to Water f1 ❑Casing to be Perforated from ft to ft (\ <br /> Sealing Material ❑Neat Cement(94 lb hag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets <br /> ElBentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other ? - <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH-,.SAN ' <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSERS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> W()RKERS COMPENSATION LAWS. <br /> M MUM 24 HOUR ADVANCE NOTICE LUREFOIZIAISPECTIONS <br /> 1 SIGNED TITLE DATE 4/7/) <br /> i <br /> --PAN E4 44T <br /> 7 Inn <br /> 1 <br /> r <br /> i <br /> { <br /> t <br /> i N at H <br /> f DEPARTMENT USE QNLV <br /> Application Accepted By Date Area Employee 1D#-t 0"{/ <br /> Grout Inspection By Date 11 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> { Destruction inspection By Date Constructed Well Depth ft <br /> i COMMENTS TfZfJr E401C jS MA4 _b k- <br /> P SC Amount c1XP' Received Permit! <br /> ^----��'' Date Invoice# Well ID# <br /> Codes Info Remitted ash B Service Request# <br /> E H D 43-02-006 MASTER WATER WELL PERMIT <br /> 5171200? <br /> f <br />