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i WELL /'PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D )LL(209)953-7697 a MENT 304 E WEBER " FL-STOCKTON CA 95242 - (209)468-3420 NON-REFUNDABLE PERMIT �►LL 209 953-7697 FOR INSPECTIONS -?I RES l 1Z ' JOB ADDRESS S6SA']t//ICI Q CITY/ZIP -w CROSSSTREET �--U-E A�PjN I //I}�� /O" �Z� PAR EL [ZE � ' OWNER NAME C' /7 � p�G4��n" '"" �I Pt10NE !r . i OWNER ADDRESS CITYISTATE!"LIP 4 CONTRACTORN S PHONE CONTRACTOR ADDR$SS CITY/STATE/ZIP CO� SUBCONTRACTOR PHONE�7 -7 SUBCONTRACTOR ADDRESS . __`/� � - -.-- _ CITY/STATE/ZIP ef LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER Z - EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section 1 INTENDED USE omestic/Private i; ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If differem from Owner: Waler ysiem Name Comaci Name or Phone um er J TYPE_OF WORK XeW Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole 11 Other S number or wells number of borings number or❑Monitoring Wells) E3 Soil Boring(s) ❑Geotechnical bf b � ❑Well Destruction '' ❑Out-Of-Service,Well ❑Out-Of-Service Well Renewal ew Pump Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTiO i Drilling Method vlud Rotary I❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other I! iProposed Well Depth ft Excavation in diameter ❑Open Bottom ( suet Pack/Gravel Size in diameter �-' 0 Conductor Casing in diameter l��nductor Casing Depth ft Weil Casing Diameter—&—in �Thickness/Gauge/ASTM Sch611" ❑Steel )lastic ❑Stainless Steel ❑Other r Grout Seal Depth_ ft ❑Neat Cement(94!b hag 15-10 brad water) ❑Sand Cement sack prix!7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ump Contractor 11Other ❑Concrete Pedestal' Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMPbmetsible ❑Turbine ❑Other HP Pump Set /&O t Standing Water Level v�� fl WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter li in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to tt Sealing Material ❑Neat Cement(94 lb bug/S-1.0 gal water) 13 Sand Cement sack mix l7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped it ❑Free Fall ❑Other El 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,I 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 CO ATION LAWS. M 24 HOUR ADVANCE NOTICE REQU RED FOR I SPECTIONS SIGNED TITLE �` �� DATE !' TT n � - t r i DEPARTMENT'USE-ONLY Application Accepted B Date 1"1 1" 'L Area 0 Employee ID# S tCJ Grout lnspectio By / j -�[-] $PEC-IA•L WCIL Pet rtsit � Pump inspecti Date�/ /�� ❑ WAIVER Received _ n� Destruction Inspection y Date Constructed Well Depth COMME !�• PE SC Amount Check#! Received Date Permit/ Invoice# Well ID# Codes Info Remitter! Cash By Service Request# `{ --b a d 800321'96 EHD 43-02-006 MASTER WATER WELL PERMIT 5nn0a2 is