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WELL / PUMP PERMIT 9f, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBERAVE 3"a FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS { CITY/ZIP <br /> — a <br /> QQ L[ p v <br /> CROSSSTREET ,�y /PN Lf � �PA..R�C/JEL SIZE ` -�� LAND USE APPLICATION# � <br /> OWNER NAME ..DTT ter,di rA T ,�-a�-y (/L� L J'1 % PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR K 6 aQ�7 �.Q..� [� _ _ PHONE{ <br /> CONTRACTOR ADDRESS 23/,S `Vr,�/s^ `• CITY/STATE/ZIP_ hC-k+0^ - CA <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER / <br /> EXPIRATION DATE 'f <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private. ❑Irrigation/Agncultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> X <br /> ❑Public Water System <br /> If different from Ownei' Water System Name onract ame nr one Num r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) Jofwells ❑Soil Borings) sfofborings p-t-reotechnical of borings <br /> i <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> f <br /> Proposed Well Depth !S R Excavation fll" in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft -41 <br /> Weil Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other s <br /> Grout Seal Depth ft ❑Neat Cement(94/h bag 15-10 gal water) ❑Sand Cement suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name .— ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Retardant!Accelerator(name) <br /> PEDESTAL Installed By ❑Dnller ❑Pump Co,'tlractor ❑Other `- <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe �1 <br /> PUMP ❑Submersible ❑Turbine ❑Other HP` Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Deptii to Water ft 13Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lh bag/5-10 bar water) 11Sand Cement sack mrx/7 al water Bentonite Pellets <br /> 13 Bentonite(20%solids) ❑Manufacturer Spec%solids__ % Name 'I It pecs on File ❑Specs Submitted <br /> FA <br /> Placement Method ❑Pumped ❑Free Fall QtheF—�aL <br /> 1 <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. r <br /> MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ( �1 <br /> SIGNED TITLEDATE <br /> DATE / <br /> 16 <br /> MW-1 <br /> (5.98) ! --"Ay M L <br /> NOV <br /> i i ll SAENVOIAONI <br /> HEALTH QE' <br /> DEPARTMENT USE NL <br /> jV <br /> Application Accepted By � Date ( L' Area <br /> 2-1 L' Employee[D# Lfs'& <br /> Grout Inspection By Date ❑ SPECIAL Well Perynit ! <br /> Pump Inspecton <br /> 'y r Date ElWAIVER Received <br /> Destruction InspeBy G7 Date����o Constructed Well Depth ft <br /> r NTS <br /> PE SC Received Chec Amount Date Invoice# Well 1D# <br /> Codes Info By u2sh Remitted a ues <br /> 1,50 00 40 Z:7G <br /> EHD43-02-006 MASTER WATER WELL PERMIT <br /> 12/22/2003 <br />