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WELL/PUMP PERMIT ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'Ito DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLF PERMIT 'IAJ' /,� ��//�'�{/1I/O)),'9)95176971ORINSPII( EXPIRES I YEAR FROM DATE ISSUED JON ADDRESS I' Z.[ 7 ✓ "`YtdSal Y`--'L/ _ 1I CROSS STREET -"�"� �- _ API _ � V � PARccLSIZE GWNEN NAME _ � .��1'�„�+✓-�__.. _-.- -. PHONE no .. O%NERADDRESS _ CITY/STATEILIP �y[� CONTRACTOR --,` Y� Y PHONE_'&Z&Z CONTAACI'OR ADDRESS_.. D_70�2_ ` _ CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS _ _ CITY/STATFJZLP LICENSE ❑C-57C-61 ❑D-09 ❑Other NuKust EKPIRAmON DATE GEOGRAPIIICALINFOR111 TION: CBBPd1Rates X Y Township_ Range Section INTENDED USE ❑Dooeslic)Privatc 0 lrtigation/Agricuhund ❑Industrial ❑Water Quality Monitoring 13 Soil Sampling/Charucterization ❑Public Water System _ If diA m Gam Ownv: Woe Syg Name Conran I—or Pb—Number -- TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlterationJModification ❑Test Hole ❑Other ❑Monitoring Well(s) numbaofwdla p Soil Boring(s) amM,er ortxxiags [3 0.t bmcM ramibc oTlaxiaga ❑Well Destruction O Out-Of-Service Well ❑OutOfService Well Renewal eiAl'New Pump ❑Pump Replacement Repair ❑Cross-Connection Repair WELL CONST ION Drilling:Method 0 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑CMhcr _.. . _._ Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other_ Grout Seal Depth----- R ❑Ncat Cement(9416 bag/5-10ga/Muter) O Sand Cement sack mix/7 gat water ❑Bentonite(20% o]ids) ❑Manufacturer Spec%solids % Name O Specs on File O Specs Submitted Grout Placement Method ❑Pumped ❑Free FaB ❑Other ❑Retardant/Accelerator(name) PE.DENIAL Installed By ODriller ❑Pump Contractor ❑Other____ ❑Concrete Pedestal Dimensions: Width_R Length_R Thick in ❑ChPYIy Bu 0 a Pipe PUMP ❑Subme ible ❑'turbine ❑OhMr HP Pump Set R SUmdiogWafaLevd_ ____0 AA WELL DE.rrRUCrlon ❑Open Bottom ❑Gravel Pack ❑Uncased O Other � Well Diameter-__in Totai Depth R Depth to W ater R ❑Casing to be Perforated ftom ft toR �®'!� �� Scaling Material ❑Neat Cement(941b bag l 5-10 gal anter) ❑Sand Cement wa sack mix/7 gal ter O Bentonite Pellets 4a ,� e® ❑Bentonite(20%solids) ❑Manufacturer Spec%solids__% Name 0 Specs on File ❑Specs Submitted L Placement Method ❑Pumped ❑Free Fall O Other_ _ ` r ® / ^�� ❑Complete,with Mushroom Cap ft below grade O Complete to Existing Surface Pad t HEREBY CERTIFY THAT HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S .IQ JOAQUIN CO . ORDIN, LACES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE ISEJJVI,, Uo V CO(J WORKERRS CURRENT con ry TI CALIFORNIA CONTRA TORS STATE c NOTICE R QsE BOARD AND THATSPECTIONS COMPLIANCE WITH ALTH Q PMS AR r�T TITLE `'� DATE l I PARTMENT U NLY Application Accepted B Date Area -[ Employee ID# Grout Inspection ByDate 13 SPECIAL Well Permit Pump Inspection By__ V �'\`\ -\Dated/!_ ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth COMMENTS --PE SC Reeelved hec Amount Date Permit/ ---- Invoke# Wei HI# Codes Info uh tfted Service R nest# J j EHD.13-02-(06 WEB `Nell PCml1.,W Declamon.doc 9'11x2007