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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DA.,r/TMENT 304 E WEBER. J"o FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL. 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS `l `�O i, ,( lbo CITY/ZIP L'�.1�\ a CROSS STREET APN PARCEL SIZE 7� n OWNERNAME , O1\�1'1 L 1 \-Z �1---f1-\ PHONE OWNER ADDRESS �Vy\C� CITY/STATE/ZIP CONTRACTOR PIIONF. CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE O SUBCONTRACTOR ADDRESS CITY/STATE/'LIP Al- LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE ? GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range - Section G",• INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IrdilTerrni rmm O .,: WsW Njelen Nrin. C ounct NNone or Phone Nuinther TvPE OF WORK ❑New Well ❑Replacement Well ❑Well Altcmtion/Modification ❑Test Bole ❑Other ❑Monitoring Well(s) anno,.r.en. ❑Soil Boring(s) nomberufbunngs 11Geolechnieal nunrer of wrings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement 1110ump Repair ❑Cross-Connection Repair 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 Sin in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth fl ❑Neat Cement(94 If hag/5-10 gal wafer) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ fl Length—ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other His Pump Set It Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water 11 ❑Casing to be Perforated from ft to fl Sealing Material ❑Neat Cement(94/b bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap fl 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. 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 WORKER OMPENSATION LAWS. M IMUMd4 DVANCCEE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 ^C $I ED ��- ��✓� TITLE CDVV ��-'` DATE v 61 C HI At T I SE RIAES � 1 �� - DEPARTMENT USE 9.91-y/ Application Accepted By Date !/ Area �/ y Employee ID# Grout Inspection By n -y Date ❑ SPECIAL Well Permit (/7d Pump inspection By lN,./I//e: "- Date C�3 ❑ WAIVERRecelved Destruction Ins ec}}r1ggnn//gg�� Date COMMENConstructed Well Depth It TS7T�G7 PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By as Remitted Service Request It �l v —71 e QC 0034630 EHD 43-02-006 MASTER WATER WELL PERMIT 12/612002