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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L :,RTMENT 304 E WEBEt.l_� ,3""FL-STOCKTON D20 n NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED to JOB ADDRESS4EA74- A?-4Q CITY/ZIP m a CROSS STREET APN� �, `�a PARCE G` hyf OWNER NAME OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR cAi.azaw W1441" PHONE f l i CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE i' SUBCONTRACTOR ADDRESS CITY/$TATEIZIP ' LICENSE 2C,'-57 ❑C-61 :❑D-09 CJ Other NUMBER _0/ EXPIRATION DATE GEOGRAPHWAL INP05,MATION, Coordinates X V Township Range Section_..; INTENDED USE omestic/Private ❑irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charartei iition ❑Public Water System If different fromOwner: Water System Name Contact Name or Phone Number TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification C]Test Hole ❑Other ❑Monitoring Well(s) number of wells number of borings number of borings g ❑Soil Boring(s) ❑Geotechnical ❑Well Destruction i, ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION� Drilling Method f;Kd Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Prop?,sedWell Depth _`eo ft Excavation f in diameter ❑Open Bottom Er6rravel Pack/Gravel Size in diameter ❑Conductor Casing' in diameter / Conductor Casing Depth ft Well Casing Diameter in .,Thickness/Gauge/ASTM Sched_ 142 ❑Steel 5Wastic ❑Stainless Steel ❑Other Grout Seal Depth _ft 13 Neat Cement(941h hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water 113 Bentonite(20° solids) ❑Manufacturer Spec%solids % Name .�Q�� bees on File 11 Specs Submitted Grout Placement Method Fd roped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Plump Contractor ❑Other ? ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Pump;! ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELLDESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased CI Other Well Diameter in Total Depth. ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941b hag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I 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 6 i 1 1 24 HO ADVANCE NOTICE REQUIRED FO SPE TION—>rLEASE CALL(209)953-7697 ElL SIGNED TITLE DATE � 4r ¢ 1 r' i 5T1G / Z 0 DEPARTMENT USE ONLY Application Accepted By Date t t Area . Employee ID# :;Grout Inspection B Date '7_0 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date !Constructed Well Depth ft ! COMMENTS /� LGCrA-RC 1 ! S O7S !G 5 PEP SC Received Check# Amount Permit/ Codes Into By ash Remitted Date Service Request# Invoice# Well IDN E, EHD 43-02-006 rO Zd MASTER WATER WELL PERMIT 12/6/2002 ��,�� C ✓LC! z� -. s Q�� .V�