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`fir' WELL /PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBE*4w0E 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED �/r !A J09 ADDRESS O /CIITYY/ZIP Lam/ S C[tf�//-yy� CROSS STREET 6 APN O f/ PoARCEL SIZE �� OWNERNAME - qq r SPII[/ONNE / OWNERADDRESS IP CONTRACTOR CPH NE _ CONTRACTOR ADDRESS ✓ CITY/STATE/ZIP SUBCONTRACTOR PHONE O SUBCONTRACTORA ESS CITY/STATE/ZIP Q LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER 9919 EXPIRATION DATE r GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Doestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization r ®'Public Water System LAIf)� Y. O�ftZ� C Ifdifferenr from Owner: Wmm Sysmm ems. om I me or one um r G. �1 TYPE OF WORK ❑New Well MIl6eplacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells Soil Boring(s) numberofbonnp ❑Geotechnical numberofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method "ad Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point� ❑Other Proposed Well Depth .� ft 2 Excavation / in diameter ❑Open Bottom F7ti'ravel Pack/Gravel Sia tPX/G in diameter O Conductor Casing in diameter / Conductor Casing Depth ------- -ft Well Casing Diameter -4—Lin Thickness/Gauge/ASTM Sched !7&429Z-2/ ❑Steel if r lactic ❑Stainless Steel ❑Other Grout Seal Depth 20Q it ❑Neat Cement(94161awg/5-10 gat wafer) "and Cement Sack mLr/7 gal water —( ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted C l Grout Placement Method 111-I'aumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller rump Contractor ❑Other qj = �ncrete Pedestal Dimensions: Width ft Length R Thick in 13Chr{sty Be. ❑Stove Pipe PUMP ❑Submersible 11 Turbine ❑Other r HSP Pump Set R Standing Water Level It z WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from fl to it Sealing Material ❑Neat Cement(94/A Aug/5-/0 gal water) ❑Sand Cement suck mix/7 gal water 11Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 0 Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRAC A LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Vill NIMUM 24 HOUR ADVACE UIR D FORM SPECTIONS SIGNED d' TITLE ATE / Is- G G H N C JEARTMENT USE ON Yr Application Accepte Area Employee ID# •JO�� Grout Inspection BykN� Date 1 00 •I� ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COMMENTS PE SC Amount ChReceived Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Re uest# Y 1�� U 1r� a feoca 0 7 EHD 43-02-006 MASTER WATER WELL PERMIT 5/70-002