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SWELL 1 PUMP PERMIT a . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D9,,. .I'MENT 304 E WEBER, ir"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CAIJ.(209)953-707 FOR I INSPECTIONS EXPIRES ] E R FROM DATE ISSUED Z-,l G 5r"J J013 ADDRESS CITY/ZIP CROSS STREET �1 APNII r 120—�S PARCEL SIZE � ^/ M OWNER NAME trG4222 A . PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR] 1)a,GI1� J cO1—r PHONE ./ CONTRACTOR ADDRESS V C �/ CITY/STATE/Z[P /G SUBCONTRACTOR - PHONE SUBCONTRACTOR ADDRESS . CITY/STATEIZIP LICENSE; ❑C-57 0•C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOCRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Damcstic/Private Xrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 13 Soil Sampling/Characterization 1 ❑Public Water System If different from Owner. ate/System Name ontaet Name or Phone Number !t): d TYPE OF WORK ❑New Well ❑Replacement Well ,11lVell Alteration/Modification ❑Test Hole ❑Other number of wcl Is B number of borings number of borings ❑Monitoring Wells) ❑Soil.Boring(s) ❑Geotechnical I ❑Well Destruction ❑put-Of-Service Well ❑Out-Of-Service Well Renewal ❑Ncw Pump ❑Pump Replacement ❑Pump Repair *3'Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud.Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth._- fi' FAcavation_ in dinmcicr ❑niten Bottom ❑Gravel Pack/Gravel Size In diltrtictcr ❑COIIdlICtOl'Casing it)diameter / Conductor Casing Depth It Well Casing; Diameter in .'Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 11 ❑NCat(:CmCnt f94!h h,rg/5-!t)gfr/tru147) ❑Sand Cement suck mix!7 gal water 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) i PEDESTAL Installed BY ❑Driller ❑Pump Contractor ©Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material 13Neat Cement(94!h hug/5-10gul wider) ❑Sand Cement sock mix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad j I HEREBY CERTIFY THAT:1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, ST E LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMP ATION LAWS M INI OU ADVANCE NOTICE REQUIRED FO NSP CT ONS— PLEASE CALL.(209)953-7697 SIGNED TITLE DATE t.. z -�— i' H ♦`t �t t hh !l 3t.1 1 t t OT ,I DE RTMENT USFV 0.%'l ' y/y Application Accepted Ely. ' - - Date 0 Area D Employee IDN L Grant Inspection By Date ❑ SPECIAL Well Permit Pump Inzpcctian Ily Date f�� ❑ WAIVER Received Destruction Inspection Ply Date Constructed Well Depth ft COMMENTS PA " 00 oS7� PE SC Received Check#! Amount Date Permit) Invoice# Well ID# Codes info B ash Remitted Service Request# a� i C-C% 'D { EH 43-02-006 MASTER WATER WELL PERMIT 12/6/2002