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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 r ' NQN-REF6NDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDR /./ "$�! �/ , n��y�a CITY/ZIP CROSS STREET r4/Ae-t— •� �AlP ' **- 0&0--* �I PARCEL SIZE "e/ OWNER NAME �l �� !�� 1�J //GC M PHONE 1�/� �q 71165 1;�WA OWNER ADDRESS �7r] ��t' �I /"�� CIT TATE/ZIP /')�-t hi/1_G lf'''r' CONTRACTORAA-z / �i_l I - PHONE CONTRACTORADDRESS. G_ � CITY/STATE/ZIP ��/�f�f�• �� y��J SUBCONTRACTOR /" ^� � � �1 ZZ� ^ ✓ "` Fe d4VO� PHONE 2j � ` -V4/Un SUBCONTRACTOR ADDRESS M - CITY/STATE/ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER T;/tf EXPIRATION DA'L'E GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization . ❑Public Water System m If different froOwner: Water System Name Contact Nume or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Mod cation ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(s) number ofborings ❑Geotechnical number ofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal v' ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTIO Drilling Method PrMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed WellDepth 4A20 tt Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 27-#CO❑Conductor Casing in diameter / C nductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bug/5-10 gal wafer) ❑Sand Cement suck mix/7 gal water \ ❑Bentonite(20%solids) ❑Manufacturer Sec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other 21, ❑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 t Sealing Material ❑Neat Cement(94/h berg/5-10 gal water) ❑Sand Cement suck 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 1 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. 1 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 COMPENSA ION LAW . M M 24 HOUR ADVANCE NOTICE UIRG FOIj1AI-RECTIONS SIGNED TITLE DA'Z'E -9/7L KIM CNI Mull r DEPARTMENT USE NL t� V' Application Accepted By Date / ea r Employee ID# 1©-J.., Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft / COMMENTS T - - �� Q P9 SC Amount �- Check#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Request# 431(l /69/ 1 /50)c 5-/,) EHD 43-02-006 ��/�Gs /� ��/ ��'� s� �� '� - M TER WATER WELL PERMIT