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WELL / PUMP PERMIT S�N JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE aka FL-STOCKTON CA 95202 - (209)458-3420 *BION-REFUNDABLE PERMIT CALL(209)453-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 7� l/f CITY/ZIP � �/ � G2 CROSS STREET APN PARCEL SIZEAND USE APPLICATION# OWNER NAME (/ P /j //]Q /� �HyO� !NE _4:/- OWNERADDRES - 6L el CITYISTATEIZIZL! D 6, CONTRACTOR 4T � �/ PHONE /, CONTRACTOR HOyNE �e I CONTRACTOR ADDRESS �.J� ` ! SUBCONTRACTOR PHONE SUBCONTRACTOR AD S CITY/STATE/ZIP / 112 L uNsE -57 ❑C-61 ❑D-09 ❑Other NUMBER Z EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinites Y RAHTI -- au. tl� INTENDED USE ❑Domestic/Private ... L?oGigation/Agri ❑Industrial 19 Water quantf t4onivoift L—f]Wtlsaih+liik)i-ihgracterization ❑Public Water Systm em. t If different from Owner: aler System NamePermito e TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification WmMrw G Ehp � 01I 5 c l O Monitoring Well(s) #of wells ❑Soil Borings) Wo"'Ovi .nr m ❑ � t� Fldtl niy ,:;l ,gfborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well'RenewalF�� ]] ❑New Pum ❑Pump Replacement ❑Pum2 Repair ❑Cross-Connection Repair WELL CONSTRUCT IIONr Drilling Method lB'Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point Other r Proposed Well Depth ft Excavation)_f in diameter ❑Open Bottom I Gravel Pack/Gravel Sizelin diameter f ❑Conductor Casing in diameter I Conductor Casing Depth H Well Casing Diameter 4D_in Thickness/Gauge/ASTM Sched 16_0 ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Dept - /� J ft ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement sack mix/7 gal water entonite(20%solids) ❑Manufacturer Spec%solids % Name 6ZOW'waL EZ C�pecs on File ❑Specs Submitted S Grout Placement Method K?Pru-mped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Ff.mp Contractor ❑Other {� ❑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 fi to ft Sealing Material ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack 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 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 4 WORKERS COMPENSAT ON LAWS. = i M1 [MUM 24 HOUR ADVANCE NOTICE VQUIR INSPECTIONS SIGNED TITLE DATE 1 YZ i 7 -H-.t:_- ___ .. _— •- ....-i. .a.�..-�.,ems.r_F '_-" r - - .-Y r -DEPARTMENT-USE ONLY -- Application Accepted By l Date Area Employee IDh� Grout Inspection By �S Q.P_ t� Date ❑ SPECIAL Well Perfflit Pump inspection By Date ❑ WAIVER Received 6 Destruction Inspection By Date Constructed Well Depth ft COMMENTS D Z6 y I PE SC Received Check#1 Amount Date Permit/ Invoice# Welt ID# Codes Info B as Remitted Service Request# EHD 43.02.006 '" MASTER WATER WELL PERMIT t2122f2003