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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE:.—RTMENT <br /> 304 E WEBER/­-;3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� t <br /> CITY/ZIP (1 GLS 3E a <br /> CROSS STREETAPN 2-2-C � IIQ I� C <br /> PARCEL SIZE �c <br /> OWNER NAME J to <br /> 9 f L.✓t k PHONE 73 <br /> OWNERADDRE55Z2 -3 Y `Z CITYISTATE/ZIP f J <br /> CONTRACTOR <br /> PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ter+ <br /> SUBCONTRACTOR I <br /> I PHONE ` <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBERz <br /> 73 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 'Domestic/Private ❑Irrigalion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampting/Characterization <br /> ❑Public Water System <br /> Ifdifferent from Owner. ater ysrem ame <br /> an[act ame or one um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitorin Well 5 number of wells bs <br /> ❑ <br /> g ( } ❑Soil Bori,ng(s} numer of borin b Geotechnical number of borings <br /> 11 We]]Destruction ❑out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> r-1New Pum Pum Re lacement ❑Pum <br /> Repair ❑Cross-Connection Repair UUU y <br /> WELL CONSTRUCTION + I <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth tt <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic CO Stainless Steel ❑Other <br /> Grout Seat Depth ft ❑Neat Cement(94 lb bag 15-10 bol water) ❑Sand Cement suck mix/7 gat water <br /> ❑Bentunite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ElPumped ❑Free Fall ❑Other 11Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Letigth ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ZD _ tt <br /> WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack 0 Uncased ❑Other <br /> Well Diameter in Total Depth R Depth;to Water ft ❑Casing to be Perforated from ft to ti <br /> Sealing Material ❑Neat Cement(94 lb hag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑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 WIT"E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL �. <br /> WORKERS COMPENSATION AW I <br /> M 2 DVANCE NOTICE REQUIRED FOR PECTIONS--PLEASE CALL(209)953-7697 <br /> SIGNED F- TITTLE �� L DATE <br /> I <br /> I <br /> 1251 11 <br /> IIL 1 111 . 11 F*K Ii <br /> --I <br /> PAY1A EN <br /> i <br /> I <br /> RECEIVED <br /> T <br /> n� 2 ZJ> - <br /> SP N J A <br /> H E R M <br /> EPARTMENT USE ONLY 7 <br /> Application Accepted By Date Area �l Employee 1D# � / 5 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> �07Pump Inspection By Date f B ❑ WAIVER Received <br /> Destruction Inspection By Date 1 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ AmountPermit/ <br /> Codes Into B ash Remitted Date Service Re nest# Invoice# Well ID# <br /> L1396 <br /> I <br /> END 43-02-006 MASTER WATER WELL PERMIT <br /> 12/6/2002 <br />