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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ' v r,aa a uau.304 ✓ <br /> 304 E WF.IfER AVE 3-FL-STOCKTON CA 951U2 (209)468_3420 <br /> NON-REFUNDABLE PERMIT CALL-(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I L/ i. 1 _ s Lo D/ ' <br /> + V l�-� CITY/Zlr <br /> CROSS STREET %4r"�2 <br /> t T_/ APNPin L�'� t - 36 �[a..�G o <br /> PARCEL$1[EOWNERNAME Y' rt PHONEOWNER ADDRESS CITY/STATEJZIP '] (JU 7CONTRACTORSI( PHONE 3 ( ` 7 C-CONTRACT OR ADCITY/STATE/"LIP I'Lill <br /> ,fir IQ L`` <br /> SUBCONTRACTOR A(%^i..I}�/(/(.r p(/Y7'J.�� PHONE "L/J <br /> t _ <br /> SUBCONTRACTOR ADDRESS 2�2..t� {N/(r C127.r !�f/ CITY/STATE/ZIP_ <br /> J <br /> LICENSE ,PAQ-57 O C�61 O D•09 O Other !!NUMBER �� EXPIN.\TION DATE �- �S IT <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranee Section <br /> INTENDED USE ,'ARbornestic/Private ❑Irrigation/Agriculturol O Industrial O Water Quality Monitoring O Soil Sampling/Characterization. <br /> O Public Water System fl <br /> Ifdifierom from Owner omr ystam .mc oman �m�o, one.um <br /> TYPE OF WORN sew Well O Replacement Well O Wel l Alteratioa/Modification O Test Hole O Other 4=- <br /> g <br /> OMonitorin Wells —b—f-11, numberofbonng, rrorb ni 1 <br /> O Soil Borings) ❑Geotechnical numb <br /> Cl Well Destruction OOut-Of.Service Well 0Out-01=Service Well Rene—( , <br /> New Pump O Pump Replacement q Pump Re it O Cross-Connection Repair <br /> WELL CONSTRU(;TION O. <br /> Drilling Method-Z54Aud Rotary O Air Rotary O Auger ❑Cable Too] O Push Point O Other <br /> Proposed Well Depth -33 R Excavation In diameter O Open Bottom vel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth Il (� <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Sched O Steel )<Plastic O Stainless Steel ❑Other i <br /> Grout Seal Depth _R O Neat Cement(94 1h hug/5-10 got+.user) 1-14 Sand Cement ?iIU sack,nix/7 gal water <br /> O Bentonite(20%solids) O Manufacturer Spec%solids % Name O Specs on Fi le O Specs Submitted <br /> Grout Placement Method b4lumped O Free Fall O Other O Retardant/Accelerator(name) _ <br /> PEDESTAL I nstalled 8 14D611cr ❑Pump contractor ❑Other <br /> ,? concrete Pedestal Dimensions: Width It Length R Thick in O Christy Bos O Stove Pipe <br /> PUMP JE3Subrnersible 0Turbine OOther HP PUMP Set aft Standing Water Level tl <br /> WELL DEsTRUCTION O Open Bottom O Gravel Pack p Uncased O Other <br /> Well Diameter in Total Depth A Depth to Water R O Casing to be Perforated from ft to ft <br /> Sealing Material O Neat Cement(94/h hog/540gal wurrr) O Sand Cement rack mix/7 gal water O Bentonite Pellets <br /> O Bentonite(20%solids) O Manufacturer Spec%solids % Name ❑Spces on File O Specs Submitted <br /> Placement Method O Pumped ❑Free Fall O Other <br /> O Complete with Mushroom Cap It below grade O Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI MUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ll'`i ?/�^• TITLE �(�(/vti/ DATE 03 <br /> N S �N <br /> A t t <br /> FT <br /> DEPARTMENT UD ONLY 3bb <br /> AppApplication A cc B� �1, / Date " Area -111— Employee ID# 5 <br /> 2Q--- e� to y Date may/Qj ❑ SPECIAL Well Permit <br /> Pump ins Zion By Date 9���l ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Amount Clteck-4/ Received Date Permit/ Invoice# Welt IDN <br /> Codes [are Remitted as BY Servlce Request# <br /> 0 21 a5 <br /> IWO <br /> s0 <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 5/72002 <br />