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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I1111ARTMENT 304E WEBEPW, E3an F6-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)251-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 22-2-cc I CITY/ZIP \ T ��TI pIn qq p CROSSSTREET , APN ,.C.C(� 0b ) C:J PARCEL SIZE LAND USE APPLICATION# p OWNER NAMEG N^ ` PHONE 6 OWNER ADDRESS CITY/STATE/ZIP �� ^V ^ c�"'! CONTRACTOR 2'lot PHONE L`0=CJJ �� CONTRACTOR ADDRESSG i � at �(�n CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ( CITY/STATE/ZIP p- .LICENSE ❑C-57 ❑C-61 ❑D-09 Arother `—/O NUMBER EXPIRATION DATE p GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ INTENDED USE ) Mmestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IfdiDerentfrom Owner: Water ystcm ame Contatt Narrator Phone Numner TYPE OF WORK ❑New Well, ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) q of wells ❑Soil Boring(s) s of borings ❑Geotechnical s of borings ^ c ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump 4vumpReplacement ❑Pump Repair ❑Cross-Connection Repair 1" WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel ❑Plastic ❑Stainless Steel 17 Other x v! Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-/0 gal water) ❑Sand Cement s#ck mix/7 galwater ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 17 Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other C` ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box O Stove Pipe C PUMP ,Submersible ❑Turbine 0 Other HP Pump Set_( ft Standing Water Level .It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Unaged ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from R to ft Sealing Material ❑Neat Cement(94 lb bog/5-10 gal water) 13Sand Cement sack mix/7 gal water ❑Bentonite Pellets A, ❑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 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS C CURRENT ND-ACTIVE NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WOR COMPEN N LAWS. IN OUR ADVANCE NOTICE E UIRED FO INSP CTIONS SIGNE TITLE DATE y Q re r C ail -it A M D - - - DEPARTMENT USE ONLY Applicanon Accepted By Date Area Employee ID# X— Grout Inspection By Date [3 SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Dare Constructed Well Depth ft COMMENTS PE SC .Received Chec Amount Data Permitt Invoice# Well ID# Codes Info B Cash Remitted 'Service Request# O SUlet 13g0o D 1p 5R-00.3 Ci S rZ- EHD 43-02-W MASTER WATER WELL PERMIT 12=003