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e�CiN WELL/PUMP PERMIT SCANNED <br /> 1 SANJOAQUCOUNTY RNVIRONMENTAL HEALTH-...,PARTMENT 304E WEBL ,✓E3""FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES 1 YE R FROM DATE ISSUED <br /> JOB ADDRESS r7 �-. CITYIZIP �n ��t/�' A VV <br /> / /� d <br /> CROSS STREET �C�tAPN O 91-3- V OI PARCEL SIZE &7-':LAND USE APPLICATION R <br />- LLL OWNER NAME /! Com`\+�I /91C ID 11 PHONE <br /> OWNER ADDRESS 4P CITYISTATEIZIP r7 <br /> CONTRACTOR PHONE ��9 ��-2 CjI <br /> CONO <br /> TRACTORADDREss CITY/STATE/ZIP 7;;,k'IG <br /> SUBCONTRACTOR PHONE <br /> t <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE 91ti-57 t W1151 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X 'Y Township Range Section <br /> INTENDED USE DomesticlPrivate ❑In igation/AgTicultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> !!! ❑Public Water System <br /> Irdiflo—t fmm Owner: .ter SySlern .— Contact ame"r one u r <br /> Fj <br /> TYPE OF WORK ❑New Well 13 Replacement Well E3 Well Alteration/Modification 0 Test Hole ❑Other <br /> E3Monitoring Well(s)_____j� tJ of wells ❑Soil Boring(s) x of borings Q Geotechnical #of borings <br /> ❑Well Destruction 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> gLiew Pump ❑Pump Replacement ❑Pump Repair d Cross-Connection Repair <br /> F, WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger 13 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> i Well Casing Diameter_in Thickness/GaugeIASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement ,rack mar 17 gal Water <br /> ❑Bentonite(201/.solids) 0 Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted `n�1 <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor AkolhCr 426!7 dt I? <br /> ;fContretc Pedestal Dimensions: Width R Length ft Thick in 17 Christy Box ❑Stove Pipe <br /> PUMP Ellubmemible ❑Turbine ❑Other HP /`I" Pump Set A Standing Water Level -._.-ft <br /> WELL D68TRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ' ft Depth to Water ft ❑Casing to be Perforated from R to R <br /> Sealing Material p Neat Cement(94lh bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> Q Bentonite(20°/"solids) ❑Manufacturer Spec%solids /, Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall CI Other <br /> Cl Complete withMushroom Cap ft below grade ❑Complete to Existing Surface 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 /> MIN M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE ^C+�./ DATE <br /> I - <br /> I nn i <br /> Fi ?C­ 11 <br /> r <br /> FiRill I <br /> DEPARTMENT USE ONLY y <br /> Application Accepted By Date Area Z Employee ID0 ,5�'e�-7 ,6 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> # Pumpinspection ' Date 7,- /-/I - ❑ WAIVER Received <br /> Destruction Inspection By. Date ', Constructed Well Depth ft <br /> COMMENTS S-4x J% -. ?�C. � F'C � Q' C..� �i",'A�tL.6?tTr[.c't.'V'"�LL ✓ +L•/"G L'� Z-aPf.- iA1 <br /> PE SC Received ec Amount Permit! <br /> {� Date invoice H Well ID71 <br /> Codes Info B Cash emitted Service uest# <br /> � EHD 43-02 W6 MASTER WATER WELL PERMrr <br /> y IN2=003 <br />