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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTAF6ARTMENT 304 E WEBEQ E 3Xe FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT �jyJ�jC/�ALL(2009)9S3-7697 FOR INSPECTIONS EXPIRES I YEAR FRR/OMM/DATE ISSUED JOB ADDRESS / - O ✓1 Mr2/ -/ /e^J CITY/ZIP -/�TQI `Q ( Je/�� P a ,/A y 0 CROSS STREET C� / APN l/�JU�t�O 2-0 PARCEL SIZE �� LAND USE APPLICA/TION#QJ CJ p m OWNER NAME (7rY /� f i/ 'er�Ga.� /�Gi(�S' (f-(k / G,,3� 917 v/—E." OWNERADDRESS 2L �v�.fLie �> �/ CITY/STATE/ZIP (f—( yl�ae^"� � CONTRACTOR �+/ P7�✓ ✓ ` Al if(r f PHONE TTT CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Itdiffermt from ner:, Water Sprott Name Contoot Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of bonngs ❑Geotechnical x of borings ❑Well Destruction AOOut-Of-Service Well ❑Out-Of--Service Well Renewal ❑New Pum ❑Pum Replacement Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other �I++ Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 'h ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-/0gal water) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted m Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other f.. ❑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 1Bryr� WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other 111 Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to it 13 \ Sealing Material Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water 0 Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec o/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 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. l 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 C PENSATION LAWS. INIM J 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED �' TITLE OW 'v_ DATE e .y ..... ri ... _.. I ... M NT yt K .. <tv ..._ D TT _—DEPARTMENTYt$ tut _— Application Accepted By Area Z Employee ID# s3�O `%fjgJ Grout Inspection Date ❑ SPECIAL Well Permit / r nspec on By Date��.�'�</ ❑ WAIVER RCCelved Destruction Inspect) Date Constructed Well Depth it ©�.�� PE SC Received a Amount Permit/ Info B Cash emitted Date Service Re nest# Inv e# Wail 1D# 0 W I� MASTER WATER WELL PERMIT