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'WELL 1 MP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Av-:3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA JOB ADDRESS I )xCITY/ZIP��r CROSS STREET APN AACEL SIZE��LAND USE APPLICATION# OWNER NAME [l PHONE OWNER ADDRESS ` rl j0ed. CITY/STATE/ZIP._ CONTRACTOR r PH NE-�7— CONTRACTOR ADDRESSO. ,r CITY/STATEIZIP /Csr SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATEIZIP LICENSE V<7 ❑C-61 ❑D-09 ❑Other NUMBER^ EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ' ❑Irrigation/Agricultural ❑Industrial Cl Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different fromOwner: Water System Name Contact Name or Phone Number TYPE OF WORK ew Well eplacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) l#ofwells ❑Soil Boring(s) iFofborings 13 Geotechnical fkorborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal Cl New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger able Tool ❑Push Point ❑Other � � n Proposed Well Depth ft Excavation in diameter pen Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Cps in diameter �/ Conductor Casing Depth ft Well Casing Diameter [n Thickness/Gauge/ASTM Sched teel ❑Plastic ❑Stainless Steele ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hag 15-10 gal water) ❑Sand Cement 3 -S'o?- sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Othe ❑Retardant/Accelerator(name) PEDESTAL Installed By. ❑Driller ump Contractor ❑Other ❑Co rete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stave Pipe PUMP Dolubmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal 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 I 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNEDTITLE DATE r i f l� f DEP Application Acce Date Area _y� 2— Employee ID# GroutInsp do y Date �� CJ G ❑ SPECIAL Well Permit / !/ Pump Inspec ion By Date Y' ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Bv as Remitted Service Request# o EHD 43.02-00h MASTER WATER WELL PERMIT 12122212003 '