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WELL / Y U 1V1Y MK1Vi1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Iii%RTMENT 304 E WEBE E 3"°FL-STOCKTON CA 95202 (209)46&342U <br /> N ttr'IiJNDABLE PERMIT ��C ALL(209 953-7691 FOR INSPECTIONS XP{RES l YEAR FROM DATE ISSUED <br /> . <br /> CITY/ZIP _ y <br /> JOB ADDRESS <br /> CROSS STREET APN ti y� PARCEL SIZE m <br /> y <br /> OWNER NAMEHONE <br /> OWNER ADDRESS <br /> C fl Y/STATElZIP �l <br /> CONTRACTOR� J PHONE <br /> I/I/ CITY/STATF/ZIPCITY/STATE/ZIP..I CONTRACTOR ADDRESS ��v S OMA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE -57 C3 C-61 13^D-09 ❑Other NUMBER ExpiRATION DATE <br /> GEOG"IH CAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private ❑irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> + 0 Public Water System Contact Name or P one um <br /> If different from Owner: Water System Name <br />' TYPE OF WORK ❑New Well ❑Replacement Well 0 Well Alteration/Modification ❑Test Hole ❑Other <br /> p Monitoring Well(s) ❑Soil Boring(S) �— <br /> numberofwells number of borings C3 Geotechnical number of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pumni Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION r <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Paint 0 Other Q <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conducto�r�Ca�sing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diamete�.lutl Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth !! �, R ❑Neat Cement(94 1b bagl' <br /> 5-10 gal water) ❑Sand Cement suck mix!7 gal water <br /> ❑Bentonite(201/o solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> k <br /> F, Grout Placement Method ❑Pumped ❑Free Fail ❑Other ❑Retardant!Accelerator(name) <br /> w - <br /> PEDESTAL Installed ❑Driller 13 Pump Contractor ❑Other <br /> 3 ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ;; :. bmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> LrESTRUCTSON pen Bottom ❑Gravel Pack ❑Uncased / ❑Other <br /> I ;��- i Diameter in Total Depth ft th to Water b ft ❑Casing to be perforated from fi to ft <br /> I Sealing Material ❑Neat Cement(941h hug/S-!0 gal water) Sand Cementsack mix 17 gal water ❑Bentonite Pellets <br /> III , ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method XPumped ❑Freefajl j ❑Other <br /> ❑Complete with Mushroom 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WITH ALL <br /> FWORKERS COMPENSATION LAWS. <br /> INIMU 24 HOUR ADVANCE N Tl REQUIRED FOR INSPECTIONS <br /> SIGNED _ �. _ ITLE�,_ �' _ DATE 1 <br /> 7 T-Flu I <br /> 41 t <br /> i <br /> �k <br /> Ari N <br /> k4t <br />