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#4793 WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 ICOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOSADDRESS 3548 N. Country Club Blvd, W <br /> CITY/ZIP Stockton 95204 <br /> CROSS STREET Wisconsin <br /> APN I2I-O3O-OS PARCEL SIZE LAND USE APPLiCATION# C <br /> O <br /> IV <br /> OWNER NAME Phil & Ann Berolzheimer n <br /> + PHONE 466-8877 <br /> OWNER ADDRESS same <br /> +" CITY/STATE/ZIP <br /> CONTRACTOR Delta Stockton Pum <br /> PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CIco1Pme <br /> LICENSE ❑C-57 XXC-61 ❑D-09 0 Other NUMBER 724778 <br /> EXPIRATION DATE ' <br /> CEOGRAPIUCAL INFORMATION: Coordinates X Y <br /> Township Range Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industria] ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. a er ystem erne <br /> ontacl erne pr one um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification 0 Test Hale 0 Other {y <br /> ❑Monitoring Wcll(s) #ofwel[s ❑SoiIBoring(s) 4 o boring #ofborirrgs V <br /> ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well Q Out-Of Service Well Renewal <br /> ❑New Pump XXPump Replacement ❑Pum2 Repair <br /> 11WELL CONSTRUCTION Cross-Connection Re air <br /> Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Too]. ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size <br /> 0 Conductor Casingin diameter <br /> m diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched <br /> ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h hag/S-10 gat wafer) ❑Sand Cementi` <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name itted <br /> Grout Placement Method ❑Pumped ❑Free Fa]] ❑Other ❑Specs on Fisack le ❑Specmix s S/7 gal water <br /> ubm <br /> ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> 7 <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thickin ❑Christy Box ❑Stove Pipe <br /> PUMP M Submersible ❑Turbine ❑Other HP 5 Pump Set 30 ft Standing Water Level 10 ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack 0 Uncased- ❑Other <br /> Well Diameter in Total Depth R Depth to Water ft ❑Casing to be Perforated from ft to R <br /> Scaling Material ❑Neat Cement(94 lb bag/S-10 gal waler) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) 10 Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted <br /> j Placement Method ❑Pumped ❑Free Fall 0 Other <br /> ©Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> 1 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. 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 /> r yJy <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLE CEO DATE 09/21/04 <br /> I <br /> 444 i <br /> r <br /> Luj <br /> FFM <br />.,.�_ -n-_ P <br /> 1- 1 IE <br /> tj — L Y <br /> Application Accepted 13y Date L. Area'._L._ Employee ID# � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit ! 11 <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMM ENTS"\ <br /> .51Y <br /> PE SC 'Received Ch Amount Permit/ <br /> Codes Info '`%B Cash Remitted Date Service Request# Invoice# Well ID# <br /> ll'f�3 q "D 'D03 790 <br /> EHD 43.02-006 - <br /> 12/22,2003 �, MASTER WATER WELL PERMIT <br />