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J/jj W EEL, i r U 1_vlr r VANLiVxx x /NON-REFUNDABLE JOAQUIN COUNTY ENVIRONMENTAL HEA >EPARTMENT 304 E WAVE 3"0 FL-STOCKTON CA 9SZOZ - (209}46$-342fl NON-REFUNDABLE/PE/R�MIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED f 7-7'ta,3 L, r�R-�,CJ� /'7J CITY/ZIP 67-0 -70 A ! �S Z-I � M JOS ADDRESS > -rAPIN3 PARCEL SIZE ACROSS STREET OWNER NAME `' �� w PI IONE y OWNERADDRESS /! ✓� n�/ CITYISI'ATEIZIP 5/1/vim / 71 CONTRACTOR PHONE ��f t✓ /�r /✓2J V CONTRACTOR ADDRESS //� � J �� __ CtTY1STATEIZIP SUBCONTRACTOR T PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP 185..1 LICENSE ❑C-57 ❑C-61 ❑D-09 EfOther NUMBER EXPIRATION DATE (�1 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section ],\ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizalion ❑Public Water System if different from Owner: Wtiiev Sysivii Nome COWLIcl Namu or Ilhow Nukobur TYPE OF WORK ❑New Well ❑Replacement Well 0 Well Alteration/Modificalion ❑Test Hole Other AM — _ [� ❑Monitoring Well(s) numberorwells ❑Soil Boring(s) numberorborings ❑Geolechnical number ofburings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair toss-Connection Repair WELL CONSTRUCTION Drilling Method Cl 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 1 Conductor Casing Depth Il Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 th hug 15-10 gal water) ❑Sand Cement suck rnis/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 Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other I Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perrorated from ft to ft Sealing Material ❑Neat Cement(94 1h hug/5-10 gal water) ❑Sand Cement sack rnis 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped El Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. HOUR ADVANCE NOTICE REQUIRED ICOR INSPECTIONS SIGNED TITLE Qf v� DATE' 1 IT r1i A I GC UN P BLI HE LTt 5 4 I .y . DEPARTMENT US NL Application Accepted By l`- Date U Area ( 11niployee IDH �3tl-G Grout Inspection Date _ [I SPECIAL Well Permit Pump Insp tion 8 Date ❑ WAIVER Received Destruction inspection By Date Constructed Well Depth A COMMENTS �l -- MS -Oi- r PE Sc Amount Received Date Permitl Invoice# Well ID# Codes Info Remitted Cash By Service Request# U d tZS Iv �' /2403 35 EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/1002