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Tom- 'P WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AYE 3"s FL-STOCKTON CA 95202 -(209)46$-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> rn <br /> l �CS•-� ��� t_ <br /> JOB ADDRESS CITYIZIP - -- -- --- a <br /> p e <br /> i CROSS STREET tit' APN �u�-r 2,10 C-25 PARCEL SIZE L -S! LAND USE APPLICATION# a <br /> // �1� C- l +1 l <br /> ONYNER NAME _Iy L-.,S pal t J C.� '�- l Q._ (1 f, t �Y -- _ _ PHONE <br /> F OWNER ADDRESS /�I11 �, -F" _ CITYISTATFJZIP , / <br /> CONTRACTOR `pn4 }- � PHONE 7[7/ <br /> CONTRACTOR ADDRESS CrTYISTATEIZIP <br /> F SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR A DDRESSS CITYISTATEIZIP <br /> LiGENSE 01C� ❑D-09 ❑Other ?NUMBER �- � EXPIRATION DATE <br /> 1 ' <br /> GEOG RAM[CAL INFORNIATION; Coordinates X Y Townsbip Range Section <br /> 1F <br /> rTENDPI)USE 4DomcsliclPrivate 13 irrigation/Agricultural 0 Industrial ❑W'aier Quality Monitoring ❑Soil Sampling/Charactenzation <br /> ❑Public Water System ,ams ns �m.r <br /> [rdiff,r ,From ti,-: aver ys��R: Horst[•am�ar o <br /> 4 TYPE OF WORK ❑New Well C Replacement Well ❑Well AllerauonlModificaiion ❑Test Hole ❑Other <br /> IFFF C Monitoring WO(s) #orweils C Soil Boring(,) "otao.fags C Geotechnical ofamings <br /> C Well Destruction C put-Of-Service Well C Out-Of-Service Well Renewal <br /> K New Pum2 C Pump Replacement C Pump Repair C Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary C Air Rotary C Auger Q Cable Tool C Push Point Q Other <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom C Gravel Pack i Gravel Size in diameter <br /> C Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge'ASTM Sched C Steel C Plastic C Stainless Steel C Other <br /> Grout Sea] Depth ft C Neat Cement(94Th hog15-l0 gai water) C Sand Cement sock mu!7 gal water 1 <br /> • C Bentonite(20%solids) C Manufacturer Spec%solids_% Name C Specs an File C Specs Submitted <br /> Grout Placement Method C Pumped C Free Fall C Other C Retardant I Accelerator(name) <br /> PEDESTAL Installed By C Dn Iler �Oump Contractor C Other <br /> 1IgConcrele Pedestal Dimensions: Width ft Length ft Thick in C Christy Box C Stave P"pe <br /> PLM1[P C,Submersible d Turbine ❑Other HP Pump Sct/,1 ft Standing Water Level R 4 <br /> \YELL DESTRUCTION C Open Bottom C Gravel Pack C Uncased C Olher -}- <br /> Well Diameter in Total Depth R Depth in Water R C Casing to be Perforated from A to R <br /> I Sealing Material C Neat Cement(94 Ih bag l5-70 gal Hafer) C Sand Cement sack mix 17 gal water ❑Bentonite Pellets <br /> D Bentonite(20%solids) C Manufacturer Spec%solids % Name C Specs on File C Specs Submitted <br /> 1 Placement Method C Pumped C Free Fall C Other <br /> r <br /> 0 Complete with Mushroom Cap fl below grade C Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION D ANTHAT THE WORK WTLL N` <br /> BE DONE IN ACCORDANCE WITH SA <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE I$ <br /> t CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT[AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAYY'5. <br /> 1l,A11' �!24 HOUR ADVANCE NOTICE LIIR//ED FOR INSPECTIONS {. <br /> SIGNEDTITLE DATE U <br /> F <br /> is f i 1r'. <br /> cr.Ft-i !`4; <br /> RH <br /> DEPARTMENT USE ONLY <br /> Application Accepted By - (ZA Date Area ���� Employee iD# rt y tf j <br /> J F Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection B Date 0 WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> F. <br /> COMMENTS <br /> kl <br /> PE SC Receivedhe Amount Date Permit! invoice# Well IDN <br /> CodesInfo $r Cash Remitted Service Re uest# <br /> 0-5,C en: �l d'Z ��c l tU l k <br /> �� EHD J3-OZ-0[Ifi MASTER WATER%ELL PERMIT <br /> 12.'21.2003 <br />