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WELL CONSTRUCTION <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT 304 E WEBER AVE 5"" FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS D85 <br />CITY/ZLIP� <br />CROSS STREET <br />APN 0 66 o �� J PARCEL SIZE 0 <br />OWNER NAME <br />PIIONII <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />, <br />Q <br />OWNER ADDRESS D / <br />CITY/STATE/ZIP / �7 <br />CONTRACTOR ' , <br />�' PIIONE 7�//•�— �(Q/�[ <br />CONTRACTOR ADDRESS DS <br />CITY/STATE/ZI <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATI IP <br />LICENSE 13C-57 ❑ C-61 ❑ D-09 <br />Other/ �/.�/ "e NUMBER 6 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates <br />X Y Township Range Section <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: <br />Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole Other <br />❑ Monitoring Well(s) <br />13 Soil Boring(s) number of wells number of borings ❑ Geot i number o ngs <br />❑ Well Destruction <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well I U D <br />11 Now Pmmn rl Pumn Renlarement fl Pumn Renair ❑ Crnss-Cnnnertinn Renair <br />WELL CONSTRUCTION <br />SEP 2 6 2006 <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ ;1ugCr ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter <br />❑ Open Bottom ❑ Gravel P�� /M �v�! S tameter <br />�>MVI�IJiN� <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />VICES <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />❑ Steel ❑ Plastic ❑ Stainless StbeIt-RMg <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag / 5-10 gal water) <br />❑ Sand Cement .sack mix / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length <br />ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP <br />Pump Set ft Standing Water Level ti <br />WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased <br />❑ Other <br />Well Diameter in Total Depth ft Depth to Water <br />ft ❑ Casing to be Perforated from ft to ti <br />Sealing Material ❑ Neat Cement (94 lb bug /5-10 gal water) ❑ Sand Cement <br />sack mix / 7 gal water ❑ Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Complete with Mushroom Cap ft below grade <br />❑ Complete to Existing Surface Pad <br />1 1 1 1' 11 1'1• <br />/• / 1' 1 1 1/ • 1 1 <br />1 •' I •' :I.1 1 • <br />'fit � �i. g a g 0 i g • <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Destruction Inspection By <br />COMMENTS <br />W -i <br />UI;PAK 1 MLN 1 USI: UN <br />Date it -6— <br />� <br />Date <br />Date <br />Date <br />Area Employee ID# d- 7 ` <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount Date Permit/ <br />as Remitted Service Request # <br />Invoice # Well ID# <br />233 <br />S !l <br />ob Q <br />EHD 43-02-006 MASTER WATER WELL PERMIT <br />12/6/2002 <br />