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WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 0 NON-REFUNDAU_LETERM IT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED J c� -i JoB AUDRESy1a w4vCrrV1ZIP CROSS STREET -C- r' VY/ APN0-20 ��_ PARCEL SIZE OWNER NAME Y PHONE OWNER ADDRESS -f7►" iw��Q� CITY/STATE/ZIP s CONTRACTOR i' V 1 ��_!�L fCSi�C y Lt tit�7 PHONE t� _ CONTRACTOR ADDRESS I J I t � �+� CITYISTATE/ZIP -P_�1 Q SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITVISTATE/ZIP LICENSE C-$7 ❑C-61 ❑D-09 NUMBER EXPIRATION DATE 2/-2Z?- v J GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Prlvatc ❑Irrigation/Agricultural Cl industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: water ystem Name ontact ame or one umber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Holc ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Borings} number Geotechnical � ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal NC— •New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary 13 Air Rotary ❑Auger ❑Cable Tool El Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth I't Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 0 Other Grout Seal Depth 11 Q Neat Cement(94 lb hag/540gal water) ❑Sand Cement .ruck unix/7 gal water ❑Bentonite(20%solids) Cl Manufacturer Spec%solids—% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Frec fall ❑Other ❑Retardant!Accelerator(name) PEDESTAL Installed By Q Driller ❑Pump Contractor ❑Oiher ❑Concrete Pedestal Dimensions: Width ft Length tt Thick_ in ❑Christy Box ❑Stove Pipe PUh1P ❑Submersible ❑Turbine ❑Other lip_ Pump Set It Standing Water Level 11 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased DWOiher Well Diameter—42—in Total Depth —4/-- ft Depth to Water ft ❑Casing to be Perforated from tt to ft Scaling Material Neat Cement(94 lb hag 15-10 gal water) ❑Sand Cement sack inix 17 gal water Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 13 Specs on File ❑Specs Submitted Placement Method 0 Pumped X-ree Fall ❑Other ❑Complete with Mushroom Clap' tt 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 WORKERS COMPENSATION LAWS. MIN MUM 24 HOUR ADV NCE NOTICE REQUIRED FOi�R\RVSP CTIONS— PLEASE CALL(20x9)953-77697 1 TITLE F)N� �' DATE, Jr'�li OS SIGNED �� (f _��{-� � S- I ► ' IN 13 PU MC EA JH �A 1 DEPARTMENT USE ONLY Application Accepted By / Date J 'ZI � _ Area �^ (o Employee ID# D i Grout Inspectior _ Date - _ ❑ SPECIAL Well Permit rd�. Pump Inspccai y Date ❑ WAIVER Received �i Destruction lnspecu n By Da`te� � � Constructed Well Depth ft COMMENTS PE SC Received heck Amount Date Permit! Invoice# Well IDN Codes Info B ash Remitted Service Request# 'al o-3 IS 5 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6!2002