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WELL / PUMP PERMIT S CAME <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 34"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 10371 E. ADA CITY/ZIP STOCKTON195215 M <br /> tra <br /> CROSS STREET PATRICK RD. APN l�3- �S"�-P2 PARCEL SIZE 7- Yf aC <br /> OWNER NAME JUAN PEREZ PHONE 474-9918 <br /> OWNER ADDRESS 10371 E. ADA CITY/STATE/ZIP STOCKTON, CA. 95215 <br /> CONTRACTOR NOACK PHONE 948-8817 <br /> CONTRACTOR ADDRESS 4500 E. FREMONT ST. CITY/STATE/ZIP STOCKTON, CA. 95215 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE YdC-57 ❑C-61 ❑D-09 ❑Other NUMBER 504513 EXPIRATION DATE 01/05 <br /> GEOGRAPHICAL INFORMATION: Coordinates 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: 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) number of wells ❑Soil Boring(s) number of borings ❑Geotechnical number of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement d(I Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Weil Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted m <br /> Grout Placement Method ❑Pumped ❑Free Fall El Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP )d Submersible ❑Turbine ❑Other HP I-, Pump Set 148 ft Standing Water Level 100 ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to fte <br /> Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets C- <br /> 0 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted m <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 24 HOUR ADVANC OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE RETAIL SALES DATE 30 SEPT. 2004 <br /> la <br /> 5 P <br /> 610�",01AP4V5 PO <br /> v — w - DEPARTMENT USE NL ' <br /> Application Accepted By Date .Z fo �- Area ' / Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit 9 <br /> Pump Inspection Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 43. rz Oso J 0c30 1-k l2- - <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 12/6/2002 <br />