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'F' <br />WL' LL / rulvir MKVIII <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH/"'N%RTMENT 304 E WEBF E 3"' FL- STOCKTON CA 95202 - (209) 468-3420 <br />I. NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS � ._.LXPIRES 1 YEAR FROM DATE ISSUED <br />[CROSS <br />B ADDRESS <br />Zr <br />CITY/ZIP <br />STREET d APN �-T-3 -2./CQ - Q <br />PARCEL SIZE <br />OWNER NAME / <br />t PHONEOWNER ADDRESS <br />``'' CITY/STATE/ZIP <br />CONTRACTOR 1/� Lf <br />" /7. , <br />//�� <br />PHONE — 2 <br />CONTRACTOR ADDRESS Pa d e CITY/STATE/ZIP g 7 <br />II SUBCONTRACTOR ' <br />PHONE <br />I <br />I <br />SUSCONTRACTOR A DDRESS <br />CITYISTATE/ZIP <br />LICENSE [I C-57 ❑ C-61 ❑ D-09 P16 her 'a f NUMBER ✓v Q �J <br />3p EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />TownshipRange Section <br />INTENDED USEomestic/Private ❑ Irrigation/Agricultural 13Industria] ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: ater ys[em ante <br />Co nme ar one um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Aheration/Modification ❑ Test Hole ❑ Other <br />❑ Monitoring We]I(s) number of wells 11nurnberorborin s <br />Soil Boring(s) s C1 Geotechnical <br />11 New Pum number of borings <br />❑ WellDestruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />(� um Re lacement ❑Aum Re air <br />WELL CONSTRUCTION ❑ Cross -Connection Repair <br />- <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth tt Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size <br />❑ Conductor Casing in diameter <br />g in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />❑ Steel ❑ plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth tt C3 Neat Cement (941h hag /S -legal water) ❑ Sand Cement <br />0 Bentonite (20% solids) q Manufacturer Spec % solids ❑Specs on File ❑ Spec % Name suck c 17 gal water <br />Grout Placement Method ❑ Pumped 12 Free Fall 13 Other s Submitted <br />❑ Retardant /Accelerator (name) <br />PEDESTAL Installed B� ❑ Driller El Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in ❑ Christy Boat ❑ Stove Pipe <br />PUMP >Gwtbmersible ❑ Turbine ❑ Other <br />WELL DESTRUCTION ❑ Open Bottom HP Pump Set �� ti Standing Water Level tt <br />P ❑Gravel Pack ❑ Uncased ❑Other <br />Well Diameter in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to ti <br />Sealing Material ❑Neat Cement (94 th hug /5-10 gut wafer) ❑Sand Cement <br />suck raix / 7 gal water ❑ Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />Placement Method ❑ Pumped 13 Specs on File ❑ Specs Submitted <br />p ❑Free Fall ❑Other <br />❑ Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION'LA WS. <br />UM 24 HOUR ADVANCE NOTICE EQU1 ED FOR INSPECTIONS <br />SIGNED TITLE 7 - 6 �--- <br />DATE <br />t DEPATZTMENT USE ONLY <br />Application Accepted By Date���� <br />Grout Inspection By Date <br />Pump Inspection By1s bid. . r <br />Date Da <br />Destruction Inspection By Date <br />COMMENTS <br />PE SC Amount <br />odesVp� Into Remitted <br />d.S-0 1 '57 — <br />EHD 43-02-006 <br />5/7/2002 <br />Date <br />Area_ Z1 Employee ID# ebr 9 <br />❑ SPECIAL Well Permit t?/ <br />❑ WAIVER Received <br />Constructed Well Depth ft <br /># Invoice tt Well ID# <br />MASTER WATER WELL PERMIT <br />