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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I ARTMENT 304 E WEBE�3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 'Com-l 11 .: [—'CSCE/j IG- - '�-- CITY/ZIP rr-d l'T �!� CROSS STREET -'�� /C�pr APN U 5 r a�3 PARCEL SIZE M R OWNER NAME � y PHONE OWNER ADDRESS CITY/STATE/ZIP s `� CONTRACTOR -�� /Jl�f r�b�rL;�� - PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP �`r7Z-,1 f-5 SUBCONTRACTOR PHONE y SUBCONTRACTOR ADDRESS CITY/STATE/ZIP rw LICENSE C-57 ❑C-61 13D-09 ❑Other NUMBER fV-7Z��EXPIRATION DATE r Z Qte 4 1'' GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section S INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization (` ❑Public Water System if different from Owner: Water Syitem Name ontact Name or PFone Number _ TYPE OF WORK 11New Well ❑Replacement Well ❑Well Alteration/Modification EJ Test Hole ❑Other number of welts number of borings number of borings 1 ❑Monitoring Well(s) A4oil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum . ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary b(Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth XV ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sea] Depth ft ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement suck 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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94lh hag/5.10 gal water) ❑Sand Cement sack mix/7 gal waterBentonite Pellets -F—&—Ca7w z ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 13 Specs on File ❑Specs Siubmt d� ' Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad j 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STA LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH TH IF IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMP NSATION LA M M 24 H A V N E NOTICE REQUIRED FOR INSPECTIONS–PLEASE CALL(209) 53-7697 ` 1 SIGNED TITLE (TrIN��'rU'-- DATE I I` r h i R N EN AL _•._-�� ;-,_� - _ _' `�` f� =r-s DEf'A•RTMENT�78E-ONLY-- ,--r=--« f-_ Application Accepted By._��y "1 y Date r brbj Area r�A I!J Employee 1D#,�vf qq� Grout Inspection By Date ❑ SPECIAL Well Permit Pump inspection By Date ❑ WAIVER Received ( (r Destruction Inspection By Date <h'.40 Construct d Well Depth ft CO MENTS / o i P SC Received heck#/ Amount at Permit/ Invoice# Well ID# f Codes Info B s Remitted Service Request# 3� S D 230 -- 51 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002