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.WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D, RTMENT 304 E WEBEk 3""FL-STOCKTON CA 95202 - (209)468-342 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS L- V 7 c`J CITY/ZIP CROSS STREET L APN �� ✓�� ~� Y PARCEL SIZE � OWNER NAME ++ ! ��6l� L C� f PHONE OWNER ADDRESS s ►,Ar`t'!; CITYISTATEIZIP CONTRACTOR � _ I WF PHONE CONTRACTOR ADDRESS 2Z2- 4F- C. CITYISTATEIZIP 8 SUBCONTRACTOR PHONE S► SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE 7 te -rl ❑D-09 ❑ e NUMBER C/ EXPIRATION DATE .A GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section N INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System N different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK M New Well Cl Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Wel I(S) number of wells ❑Soil Boring(s) number of borings ❑GevteGhnlCak number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum - ❑Pum2 Re lacement ❑Pump Repair ❑Cross-Connection Repair j 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 Size in diameter 710 ❑Conductor Casing in diameter / Conductor Casing Depth ft d Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 0 Other I Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gal water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ]I Grout Placement Method ❑Pumped ❑Free Fall ❑Other 0 Retardant/Accelerator(name) 7 PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTIONn Bottom 01 Gr e Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Ce ent(941h hag/S 10ga water} nd Cement s4��ack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20°/solids) ❑Manufacturer Spec%solids % Na ❑ ecs on,File ❑Specs Submitted Placement Method ��El-Kmped ❑Free Fall ❑Other ,complete with Mushroom Cap 3 ft below grade ❑Complete to ExisTing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT{ 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 WORKERS COMPENSATION AWS. MIN N E NOTICE REQUIRED FO PECTIONS T PLEASE CALL(209 - 9 r SIGNED TITLE DATE ;) I i P ; t VJEALTI..I DFPARW40W4NT USE ONLY �-7 / Application Accepted By V V • Iv Date_ 1" 0.- Area L-1 C� Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit �� Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date ll D Constructed Well Depth ft COMMENTS 14Z%LV PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# 3�� b So r l RC)036 9:% EHD 43-02-006 MASTER WATER W EI.L PERMIT 12/6/2002