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JVELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 r NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED. I Jon ADDRESS a4q / • 49�1� q� > a. APN �O d 2 PARCEL SI'LE a C.RI)Sti S'1'Ht:t:'1' OWNER NAME '14 'G EJ' PI Nr: OWNER ADDRESS CITYISTATEIZIP ('.IIN'TRAUT01t +� __ _.L7- ✓".�1..�._ (✓�. �—�. �-f�� _ PII(1N r: CONTRACTOR AbU vss �'/fr�� _ / CI'1'YISTATE1Z11' r� SUBCONTRACTOR � PHONE SUBC.ONTRACrOR ADDRESS CITYISTATE/ZIP LICENSE. ❑C-57 ❑C-6I fl D-09 XOLIICIL -Z NUMBER ZiWEXPIRATION DATE .. GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section - INTENDED USE 7297Mnestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Sail Sampling/Characierizatibii. ❑Public Water System if different fromOwner: Water bysrem Name ontacl ame or one Number TYPE 01:WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification C]Test Hole 0 Other number ofµellsnum0 Cacotechnicalber of borings number of boring ❑Sail Bonn L 0 Monitoring Well(s) g{5) ❑Well Destruction ❑Out-Of-Service Well C7 Out-Of-Serviee Well Renewal ;r! ❑New Pump ❑Pump Replacement Cl Pump Repair Toss-Connection Re air I WELL CONSTRUC"TION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth It Excavation in diameter ❑Open Bottom fl Gravel Pack!Gravel Size in dia ter ` C7 Conductor Casing in diameter / Conductor Casing Depth tt r}wV Well Casing Diameter in Thickness/Gauge/ASTM Schcd C3 Steel ❑Plastic ❑Stainless Steel 13 Other �n Grout Seal Depth ft ❑Neat Cement(94 lb had;/5-10 got water) CJ Sand Cement suck mix 17 gal water vl ❑Bentonile(20%solids) 0 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall 0 Other 0 Retardant 1 AcceleralOT(name) PEDESTAL Installed By El Driller O Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length R Thick in Cl Christy Box ❑Stove Pipe PUMP 1;1 'submcrsiblc ❑Turbine ❑Other HP eo__ Pump Set-6-)1-tt Standing Water Level fl WELL.DESTRUCTION ❑Open Bottom ❑Gravel Pack 0 Uncased ❑Other J Well Diameter in Total Depth ft Depth to Water R 0 Casing to be Perforated from ft to Scaling Material ❑Neat Cement(941h hug/5-10gut water) ❑Sand Cement sack mix 17 gal water C7 Bentonite Pellets 0 Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap It below grade Cl Complete to I:.Kisling SUrrace Pad j I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL KE DONE 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 I AM IN COMPLIANCE WITH ALL RT WORKERS COMPENSATION LAWS, MU OUR ADVANCE NOTICE REQUIRED FOR IN PECTIONS—PLEASE CALL(209)9_53-77697 SIGNED "I"Il-LF.' DATE —�• I IIIA JimFir P1 -49MA AN JO O IN O N i 1 zz - - -�. J DEPARTMENT USE N[Y Applic tion Accepted 13y -�� Date ir: F d' Arca Z r Employee]D# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ❑ WAIVER Received Destruction Inspection By r Date Constructed Well Depth ft COMMENTS PE SC Received Che Amount Date Permit/ Invoice# Well 1I# Codes Info B Cash Remitted I Service Request it xJ:3.-7-7 MASTER WATER WELL PERMIT EI-11)43-02-006 121612002