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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a FL-STOCr�{TON CA 95202 - (209)465-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED /T ` / � 119<3G21 V_r JOB ADDRESS coo�1 op y T , gI - CITY/ZIP S.S iGL/ m D CROSS STREET APN_7_Qq a��70 Q/ PARCEL SIZE 0 —a LAND USE APPLICATION# p � m OWNER NAME tst'mAlZ11_ �a111 M 14 I T)GG PHONE —Q2-8 as-16'46 OWNERADDRESS 3/ ),A I tq-r-)C µ CITY/STATE/ZIP :;Vy p CONTRACTOR ^ I))Cr r��rq T�-/'�II y71/y I�� IAIK- `PHONE 2-49-Z3,/ [� CONTRALTORADDR,ESSS'1gg�'I / f;Z / CI / -iJ'7'7e T CITY/STATE/ZIP 5yo& y-, CA q•s7�(-i_ SUBCONTRACTOR �,�F/T/ /J XAt_AP14=[/ZM� PHONE, 9Q�[Z, SUBCONTRACTOR ADDRESS Z3[ tj CITY/STATE/ZIP �' ,_H"r•>Jtii 4 �J$7 S ��;;1 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE Q ~, GEOGRAPHICAL INFORMATION: Coordlne[es X Y Township Z. 'S Renge I- Section --C_ INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial Awater Quality.Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferew from Owner: ate: yslem ame omed ame or one um er ,,,,,,,,,,.....!!!I U� TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hale ❑Other \/ s Monitoring Well(s)_�pafwells ❑Soil Boringgorborin Boring(s) S ❑Geotechnical poi borings Monitoring Destruction ❑Out-OF-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Re lacement ❑Pump Re air ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary [Auger ❑Cable Tool - ❑Push Point ❑Other .Proposed Well Depth M 25) ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 2 r/ in Thicknesss/GEl Steel auge/ASTM Sahed 4Q Plastic 11Stainless Steel ❑Other Grout Seal Depth A -It /, ft XNeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water { ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted f Grout Placement Method ❑Pumped Free-Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width!a- ft Length-_n.$ft Thick rr in ❑Christy Box AStove 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 I ft Depth to Water ft ❑Casing to be Perforated from R to ft - Sealing Material ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sock mix/.7 gal water 0 Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids o/ Name ❑Specs on File ❑Specs Submitted Placement Method. ❑Pumped ❑Free Fall ❑Other 0 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 RULESTAND 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 WORKERS COMPENSATION LAWS. INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE '(,7Fj1I/yK/S'Y "`'� DATE r% ------------ ------------ ------------- { ' 7--77 9 7�H$ T EF iDEPARTMENTUSE LY Application Accepted By + - Date // Areae Employee ID# Grout Inspection By Date 7T ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Dale - Constructed Well Depth ft C/O'IMMEEQNTS PE SC Received her: Amount Date Permit/ Invoice# WefI ID# Codes Info B Cash Remitted Service Re treat# EHD4Y0]-OOM1 - MASTER WATER WELL PERMIT