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WELI{% PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH"TMENT 304E WEBEI. m 3XO FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT y/CALL 209),9153-7697/FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 25 D / / \ CITY/ZIP CROSS STREET , 1 / -- APN ' �`�O —'2'/ PARCEL SIZE 1�F. 77 OWNER NAMEL-�a R7,9Jr. NOlyt PHONE ri OWNERADDRESS ,( / CITY/STATE/ZIP 1. CONTRACTOR AUS r'�it� � 7��f �,�JC PHONE . �22-3VSZ IwV CONTRACTOR ADDRESS CITY/STATE/ZIP /r s SUBCONTRACTOR bUUF V�� SUBCONTRACTOR ADDRESS CITY/STATE/ZIP V A LICENSE ❑C-57 ❑C-61 ❑D-09 ❑OtherC NUMBER66 z 73Z E%PIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE 1$Domeslic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactenzation �) ❑Public Water System Udiffere,afrom Ownec eter ys4m sme meet eme or one um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwelis ❑Soil Boring(s) numberofborings 0Geoechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump *urnp Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP )Submersible ❑Turbine ❑Other HP_%�Q PumpSet-46,6 ft Standing Water Level Z ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Unused ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to he Perforated from ft to ft Sealing Material El Nut Cement(94 lb bag 15-10 gal water) O Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec 0/a solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS MINI 24 A NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ,G- TITLE �lC //(A�TI�g/L DATE 1 11 L4 p 1 IC p 8l1 �N AI DEPARTMENT USE ONLY Application Accepted By DateArea Z"f Employee ID# 3 ^ � Grout Inspection By Date 13 SPECIAL Well Permit Pump Inspection B Date 13 WAIVER Received Destruction Inspection Date / , Constructed Well Depth It COMMENTS PE SC Received Chee Amount Date PermtU Invoice# Well ID# Codes Info B ash rnRemitted Service Re nest It 7921 .0— rl40033,f2C, EHD 43-02-006 MASTER WATER WELL PERMIT 12/62002