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I i SWELL / PUMP PERMIT j SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE, _CMENT 304 E WEBER h {"FL-STocKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES ] YEAR FROM DATE ISSUED JOB I 11 DDRESS v/ CITY/ZIP IL eG 3 9 , II �J -2 �Q C� tz CROSS STREET J ��' e G C APN 5��°� �qL PARCEL SIZE .�V•`� � tz FF[ OWNER NAME Q y Q PHONE 162, OWN EiR ApDRESS C,, / CITY/STATEIZIP CONTRACTOR !� Oi✓ G PHONE i CONTRACTOR ADDRESS Az _ CITY/STATE/ZIP E� SUBCONTRACTOR PHONE SUBCOpNTRACTOR AD DRESS CITY/STATE/ZIP Fln) 1. - LICENSE ❑C-57 ❑'C-61 ❑D-09 a Other Cr(/ NUMBER (L7QJl�_ EXPIRAT N DAT GEOGRAPHICAL INFORMATION: Coordinates ?CJ �' Township Range Section INTENDED USE omestie/Private ❑Irrigation/Agricultural 11 Industrial ❑Water Quality Monitoring . ❑Soil Sampling/Characterization 4 ❑Public Water System 3fdifferent from Owner: Water System Name orstact ame or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other O number orwells number of❑Monitoring Well(s) ❑Soil Boring(s) bf bi � ❑Geotechnical number of borings ` € ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal f� ❑New Pump ;RkUMP Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tao] ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack i Gravel Size in diameter 11 ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schell 13 Steel ❑Plastic ❑Stainless Steel El Other Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gat water) ❑Sand Cement sack mix/7 gal water �1 11Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 13 Driller 13 Pump Contractor [3 Other 11 ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 11 ^bmersible ❑Turbine ❑Other HP Pump Set 215cl ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Grave]Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Se.ling Material ❑Neat Cement(941h hag/5-10ga1 water) 13Sand Cement sack mix 17 gal water 13Bentonite Pellets 1 ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other 11 ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I JOAQUIN COUNTY ORDINANCES, STA AWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE AL ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW . I M IM 24 NCE NOTICE REQUIRED FOR I ECTIONS—PLEASE CALL(209)953-7697 f SIGNED! TITLE DATE li I� �I G lr � WIG l DEPARTMENT USE ONLY Application Accepted By Date Area �� Employee ID# 93 7Tt! 5,// Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By��5 — Date I ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft t COMMENTS PE SC Received eck# Amount Permit! Codes Info B as Remitted Date Invoice# Well ID# Service Request# h EHD43-02-006 MASTER WATER WELL PERM IT 12/6/2002