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ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE..,., TMENT 304 E WEBER wYw 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(2 09)953-7697 FOR.INSPkCTION'S EXPIRES I YEAR.'FROM DATE ISSUED JOB ADDRESS5, C- +r—�� CITYIZIP 1 CROSS STREET APN_r2 fid'" � - f�I _ PARCELSIZE OWNER NAME t PHONE OWNERADDRESS __ZS S- 6.�� -'�� CITY/STATE/ZIP CONTRACTOR • cacLst. _s,G�1 �LJ�x■ t��--1L� �_C�P�Y �QG� PHONE CONTRACTOR'ADDRESS aAlc CITYISTATEIZIP _�_rC4C� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 LYOther'bu (I—kb NUMBER EXPIRATIONDATE dS GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑]rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner Water Systern Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other tir number of wells number of 6orin umbofrgs❑MonitoringWell(s) 13 Soil Boring(s) ❑Geotechnica # WC. Destruction 17 Out-Of-Service Well [3Out-017-ServiceWell Renewal i Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair i 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 ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑-Plastic ❑Stainless Steel ❑Other f Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water 4 ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted N Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed BY ❑Driller ❑Pump Contractor a Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Su , PUMP bmersible ❑Turbine ❑Other HP _ Pump Set��ft Standing Water Level �,� ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other J'_ Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941b bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%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 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. I 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. Of MINI H UR AD N TICE REQUIRED FOR RR INSPECTIONS—PLEASE CALL(209`)953-7697 SIGNED TITLE YUY��—TeL� DATE 06-1(0 AN JO O T L DEPARTMENT USE Y ApphCatior:sA att .Bv�, _ r _ �. Date � �� s _ Area x_02 1' -Employee fD#��S195 Grout Inspection By Date ' ❑—SPECIAL Well Permit Rump Inspection ByT /lam_ Date 4 ❑ WAIVER Received Destruction Inspection By / Date Constructed Well Depth It COMMENTS PE SC Received et Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002