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WELL 1 PUMP PERMIT SAN JOAQUIN COUNTYENVIRONNtENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON r (",020 111 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS CITYIZIP yr ��,C /!//1� CROSS STREET /�-fI/�i) APN �IJI`I £I[`�7�,V �PpARCEL S�lr7.E 0k1',ER NAME c -,/y�'J /_�17� P�HOj,\'E'/7�71�.�`�/�. OWNER ADDRESS - 11:1M2 _ fes/„/ CITYISTATEIZIP CONTRACTOR (-,42/AJC /lL�IL1�N .11L_ _ ____ __ PHONE - CONTRACTOR All J DRESS .1//I/ . ejLA?'21/ C1TYlSTATEIZIP� 4 ,- CA �Zyl& SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP /�} ��7 ❑C- -2 EXPI RATION DATE LICENSE JdL--Y6l ❑D-09 13Other NL'M11HER GEOGRAPHICAL INFO CATION: Coordinates X Y Township Range Section INTENDED USE omesti0l"nvate ❑Irrigation/Agricullurai 11 Industrial ❑Water Quality Monitoring Cl Soil Sampling/Characterization ❑Public Water Svstem lFdiffemnt fram bwner: wa,,r ystem ame onset ame or ane,um er s"-'" .y TYPE OF WORK ,'ew Well In Replacement Well ❑Well Alteration/Moditication Q Test Hole ❑Other ❑Monitonng Well(s) numbere£weHs C7 Soil Bering(s) number of borings C3 Geotechnical numhcr of barmgs `-� �I Cl Well Destruction ❑Out-Of-Service Well ❑Out-Cf-Service Well Renewal \1 Cl New Pump ❑Pump Replacement ❑Pump Repair 0 Cross-Connection Repair . WELL CONSTRUCTION/ - Drilling Method @ Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other fp Proposed Well Depth.-2,�� R Excavation 14 in diameter d Open Bottom CTvravel Pack;Grose]Size ilS" in diameter Q Conductor Casing in diameter 1 Conductor Casing Depth ft Well Casing Diameter e? in Thick nesslGauge.rAST14 Sched 1G4y ❑Steel arrtastic ❑Stainless Steel Cl Other Grout Seal Depth 4aa ft 13 Neat Cement(94 16 hug/5-10 gal water) ❑Sand Cement suck mix 17 gal water el Bentonite�(20%solids) [I Manufacturer Spec%solids % Name_[s ^j�if� EYgp s on File ❑Specs Submitted , Grout Placement Method f Zped Q Free Fall ❑Other ❑Retardant,'Accelerator(name) - PEDESTAL Installed By ❑Driller P11-ump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width 11 Length R Thick in ❑Christy Box ❑Stove Pipe PU.mP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack 0 Uncased L Other Well Diameter in Total Depth n Depth to Water It ❑Casing lobe Perforated from It to tl Sealing Material Cl Neat Cement(94 1h hug 13-10 got water) Ll Sand Cement suck mix/7 gal water ❑Bentonite Pellets ❑Benlonite(20%solids) ❑Manufacturer Spec%solids % Name 11 Specs on File ❑Specs Submitted f Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade 13 Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENS TION LAWS. i E V 24�- ADVANCE NOTICE REQUIRED FO SPE TIO\ -PLEASE CALL(2097)953_7697 SIGNED TITLE DATE L Ill . /-) -14 7 - 1-�� L &A 11 2 J r1 � v ! s 1 Y - 2 ' Z• { DEPARTMENT USE ONLY, Application Accepted By _ pate 4 o + _ � Area Employee IDX Grout inspection B- Date 11 SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date 1 Constructed Well Depth ft COMMENTS 1%•I /.z M�- 'r3 � PE SC Received CheckHl Amount Date Permitl Invoice# Well IDH Codes Info By ash Remitted p ServiceRequest4 ` 97-3 �{ END 43-02-006O l Zd MASTER WATER w'ELL PERMIT 1276/2902 ;e 6*,(-L{.d 7,2.41-a AA.,rYii1