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WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT ' CALL(249)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED to r JOB ADDRESS P�L /�/^r CITY/ZIP S T�riIL��/"` �7 d�r✓� � { J ,A 9 CROSS STREET f 4 14 r GI��4--APN 1 1 �r� �� 7'WPARCELtSIZE� _LAND USE APPLICATION# OWNER NAME Aree&" 61_c, at/43., �A^t1*App"� S PHONE e OWNER ADDRESS •CITY/STATE/ZIP CONTRACTOR f� r __ PHONE ` 7? 2aU CONTRACTOR ADDRESS ��Z IJ•LOZi5�/Z-A _ CITYISTATEIZIP e,&p / C+ SUBCONTRACTOR PHONE } SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE C-57+ ❑C-61 ❑D-09 ❑Other NUMBER 3 EXPIRATION DATE d �r •GEOGRAPHICAL INFORMATION: Coordinates X Y - - ' - Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural " ❑Industrial ❑Water Quality Monitoring • $oil Sampling/Characterization r ❑Public Water System If different from Owner: stet'System Name Contact Name or Phone Number _ 14 A " A TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlterationlModiftcatio o �,.❑ _yt� ❑ r ❑Monitoring Well(s) #of wells <Soil Boring($)j °f bo g q° '' rings ❑ echntcal ❑Well Destruction' ❑Out-Of-Service We 1 ;j�� t��' itted without ❑New Pum ❑Pum Replacement '❑Pum P air ross Connection Rqpa,r _ r WELL CONSTRUCTION[ work oeing a ) L Drilling Method ❑Mud Rotary ❑Air Rotary ❑A et' ❑Cable Tool ❑Push.Point ❑ r t Proposed Well Depth _ft Excavation in diameter ❑OP Bott�m ��Favi ack/Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter *in Thickness/Gauge/ASTM Sched 0 Steel ❑Plastic ❑Stainless Steel ❑Other t Grout Sea] Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 1 7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Vzetue-legth�11 Cont ❑Other ❑Concrete Pedestal Dimensions: Width Thick in ❑Christy Box ❑Stove Pipe i PUMP 0 Submersible ❑Turbine ❑Other H ump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ;.,- ❑Gravel Pack ❑Unca ed ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft l Sealing Material ❑Neat Cement(941h bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets 1 _s .0-Bentonite(20%solids) _._❑Manufacturer Spec%solids % Name -- - s'r ❑Specs on"File*-❑.Specs Submitted- Placement Method ❑Pumped ❑Free Fall Other_,--4,�1 'r",>� Q 9/�TZs 1 TC "Q!5 F ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad Ar 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS y SIGNED - TITLE _ DATE 7 O71 5inglc -"i { �� S f Famiy © m p Ramea- _ - i � I tv j}, Single I 5th St m Family Nightingale Avenue 219 Homes 51no1e vacant'" r Single ti i Family South Portion r f=amily Heme9 Form Hc.>ia }{pme5 r- �/ �f t hMa,,aar❑i 10 Mane• 1 am_ t 1"44� V11 1777 - amid 5111,31f, •t- v 5ixt St eet I FamilY �.. - ome5, H-HomesC. r ` i - ;-"• (;r atlon: ..— -.-...:.,.azrrr-a.'_ °1QL�— �.�` Application Accepted By _ y; ��Date Area ` YEmployee ll)#'+' Grout Inspection By, •n r Date ❑ SPECIAL Well Permit ' 1 I Pump Inspection By Date ❑ WAIVER Received r Destruction Inspection By Date Constructed Well Depth ft 00\-- COMMENTS#./,I I/ yyXa06AM"_ r PE SC Received heck# o Amount Date ""' Permit) Invoice# Well ID# Codes Info B ash Remitted Service Request# 1003$ S FHD 43-02-006 MASTER WATER WELL PERMIT i2nu200i