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WELL / PUMP PERMIT N <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r' /i e CITY/ZIP � l > <br /> JOB ADDRESS > <br /> n d <br /> APN ` � I / PARCEL SIZE �t <br /> CROSS STREET <br /> OWNER NAME rte— PHONE <br /> OWNER ADDRESS - CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CITY/STATE/ZIP <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 -61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <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 ontact ame or one um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> number of wells number of borings number of borings <br /> ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well 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 <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑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 ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION �TO�jen.Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter V in Total Depth�,5_ft Depth to Water ft 13 Casing Casing to be Perforated from to ft <br /> Sealing Material j�Neat�7Cement(94 lb bag/5-10 gal water) [ISand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bent/orate(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped XFree 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 /> Ni 24 HOUR AD C N CE REQUIRED FOR INS ECTIONS-PLEASE CALL(209)953-7 7 <br /> SIGNED TITLE rP S DATE <br /> oh <br /> p(Q JIN CO N <br /> PqBU EILLI <br /> T DI SI0 <br /> jZ <br /> TFT- -1 lk <br /> DEPARTMENT USE ON <br /> Application Accepted By R"T" 0 Area_ Employee ID#-�- �—� <br /> Grout Inspection By Date <br /> ❑ SPECIAL Well Permit <br /> Pump Inspection By Date [IWAIVER Received <br /> Destruction Inspection B Date , </7"1': Constructed Well Depth ft <br /> i� <br /> 140 <br /> COMMENTS <br /> /—' G �L�t�L 11 3 eFq GeS� <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitte Service Re uest# <br /> >a-sYS / Q3 003-'J <br /> EHD 43-02-006 GI��'�KJ SG MASTER WATER WELL PERMIT <br /> 12/6/2002 <br />