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SWELL / PUMP PERMIT- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L.....ATMENT 304 E WEBER 3R°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED t_3 +'✓�l'4! to JOB ADDRESS CITY/ZIP VY�L'M'- �/V - a CROSS STREET Al bAJ S*, A_PN 159 -1a7- oxI pmt. • I `y PARCEL SIZE LAND USE APPLICATION# 7Otl OWNER NAME 1 j� ` L PHONE T /" OWNER ADDRESS U L/ /V JJ � I �� CITY/STATE/210_1_ CONTRACTOR f-kit.- 0, �/d� S� h)�� i►'JSaC r PHONE 204—3`7-"Y7 a� CONTRACTOR ADDRESS I 2_-_ _(M)t,.' ,^I- CITY/STATEIZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITrYIISSTATEIZIP �( LICENSE C-57. ❑C-61 ❑D-09,; 1:3Other NUMBER 47_ C0'r ,, EXPIRATION DATE • d S< GEOGRAPHICAL INFORMATION: Coordinates X' Y Townshlp Range Section INTENDED USE O Domestic/Private ❑lirigation/Agricultural ❑Industrial '❑Water Quality Monitoring Soil Sampling/Characterization " ❑Public Water System 1 If different from Owner: Water System Name Contact'Name or Phone Number TYPEOF WORK"'❑New Well ❑Replacement Well 13 Well Alteration/Modification' ❑Test.Hole '❑Other Q r, ❑Monitoring Wells) #of well'sSoil Boring #of borings ❑ #of borings..s) 8 '' Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal `❑New Pum "i;❑Pump Replacement ❑Pum ',Repair_ 13Crtiss-ConnedtioAlRepaif WELL CONSTRUCTION m Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool r ❑Push Pomtry ❑Other 1', Proposed Well Depth /10 flExcavation 1 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 Grout.Seal Depth ft ❑Neat Cement(941h hag 15-10 gal water) ❑Sand Cement sack mix/7 gal water ', ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method 0 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 R , WELL DESTRUCTION ❑Open Bottom ❑Gravel.Pack. ❑-Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft W. R Sealing Material ❑Neat Cement(94 lb bag/5-10 gal seater) ❑Sand Cement sack mix 17 gal water _,dBentonite Pellets If C'' ,❑Bentonite(20%solids) O Manufacturer Spec%solids % Name ❑Specs on.File ❑Specs Submitted' Placement Method ❑Pumped ❑Free Fall Other S o t t_ CA,-Mi Tris _ ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TILE WORK'WILL BE'D04'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 IAM IN COMPLIANCE WITH ALL WORKERS COMPENSATION L . AWS. :r i MINIMUM 24 HOUR,ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED DATE', � �--- � I xARbX 6MtP[N TRcoY � 6AET elpi •[ArtelHa a` • w O t Y ! i <J 1 .aT„AIR 5[ S� .,. j: - k i ar • ,�P 4 K � -Application Accepted'By"'"� Areac7-c7- i' Emp— ol'yeeel-D# - Grout Inspection By Date 0 SPECIAL Well Permit9 Pump inspection By Date © 'WAIVER Received InspectionTDate"'- ;`"= Y9 - Constructed Well Depth_-T It 1 COMMENTS "PE SC Received Check#1 Amount Permit/ Date Invoice# Well ID# Codes Info By Remitted ServicaRe uest# ,' • EHD43-02-OOfi MASTER WATER WELL PERMIT 12/22/2043 ..