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1 WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENV]RONIIIENTAL HEALY11-DEPARTMENT 1"J bz�� ,/p 304 E WE4_0 AVE 3"t'FL-STOCKTON CA 95202 - (209)468-3420 <br /> i <br /> NODI-REFUNDABLE PERMIT CAJLL(209).953-7697 FOR (INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0� a CITYIZIP <br /> t� Y <br /> CROSS STREET <br /> r A N o o cJ PARCEL SIZE 1 z <br /> y Q�' <br /> OWNER NAME <br /> 1 � PHONE GV <br /> OWNER ADDRESS CITYISTAT <br /> CONTRACTOR Al 7 . AAIIII5� `' I E '/ —�`+�Q✓ ._ <br /> s CONTRACTOR ADDRESS I/ ! � CITYISTATEIZIP �9 <br /> SUBCONTRACTOR �f �rVL PRONE vT[] <br /> -7 <br /> SUBCONTRACTOR ADDRESS � rJ <br /> / CITYISTATLI <br /> LICENSE C-57 C-61 ❑D-09 U Other NumIER A ExrtRATION DATE <br /> GEOGRAPEIICALINrORMATEON: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑IrrigatiottlAgricultural ❑industrial 0 Water Quality Monitoring ❑Soil SatrlplinglCharacterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1KNew Well ❑Replacement Well ❑Well Alleration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Wel!(s) <br /> numBoring(s)berofwells ❑Soil Borin numberofborings 11 Geotechnical numberofborings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> 1 New Pump CJ Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method jKMud Rotary ! ❑Air Rotary 11 Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well (Depth tt Excavation_ /7 in diameter ❑Open Bottom )K Gravel Pack/Gravel Size A in diameter <br /> ❑Conductor Casing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth__ ti ❑Neat Cement(941b hagl5-10gol water) ❑Sand Cement sack nnr17 gal water <br /> 3entonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout PlacementMethodumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed 8Y ❑Driller *ump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length --ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP submersible 13 Turbine ❑Other HP Pump Sct f ye ft Standing Water Level Fn fl <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth it Depth to Water ft ❑Casing to be Perforated from tt to it <br /> Seating Material ❑Neat Cement(94 th bug/5-10gal water) ❑Sand Cement sack(nix 17 gal water ❑Bentonite Pellets 1 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surtace 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 14 NIMUM 24 HOUR ADVANCE NOTICEN/QUIREI ICOR INSPFCI'IONS <br /> SIGNED � �.. �, TITLE..11���Zff�/ ��lr��L - _ DATE <br /> C, lit <br /> IDA 7rEM_t__ <br /> ' L <br /> 0� <br /> Si /// <br /> DEPARTME T F LY u <br /> Application Accepted By 2,— DF rS �1 'Z- Area Employee tD# >/ <br /> Grout inspection By Date 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ) ❑ WAIVER Received,., <br /> Destruction Inspection By Date v Constructed Well Depth �FJL) _ ft <br /> COMMENTS d <br /> PE SC Amount Check#! Received Date Permit) Invoice# WellID# <br /> Codes Info Remitted By Service Request 11 i <br /> Qoo I <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 517/2002 <br />