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�/,WELL / PUMP PERMIT // SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBENR-1VE 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR.INSPECTIONS EXPIRES I Y;j6R FROM DATE ISSUED ELI JOB ADDRESS G/� rS//ail�rw -� O CROSSSTREET //tt�'' 11�y t APN D()"/-C 0?0-0' PARCELSIZEEJ OWNERNAME [! Wd 9—, 6 L leo_ PHONE OWNER ADDRESS IQ CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR t d�-tq PHONE (�cC Q� r C'�/ -7 J ' ,� SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE HC-57 qk<l ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE I]Domestic/Private ❑Irrigation/Agricultural ❑,IInndustrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Public Water System • m //{�2��Qt• If different W from stem et yslem ame Contem Nmr.or one1G.W TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwdls ❑Soil Boring(s) number of borings ❑Geotechnical number of borings O ❑Well Destruction ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter —in Thickness/Gauge/ASTM Sched ❑Steel 13Plastic 13Stainless Steel 11Other �• Grout Seal Depth It ❑Neat Cement(94 lb bag/5-10gal water) ❑Sand Cement .sack mix/7 gal water C ❑Bentonite(20%solids) ❑Manufacturer Spec%solids %. Name ❑Specs on File ❑Specs Submitted \^V71V Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width It Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set it Standing Water Level ft (� WELL DESTRUCTION ❑Open Bottom �v/e�l�Pack ❑Uncased. 13 Other \ Well Diameter in Total Depth-1�ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal wafer) ❑Sand Cementl=-ck mix/7 gal water 11Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids—�%. Nam 13 Specs on File r❑Specs Submitted Placement Method EW.. ❑Free Fall 13 Other ULH,�J91 i -G AIpt Sn " An ❑Complete with Mushroom Cap ft below grade VComplete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TH 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 CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI 20 UOUWVANCE NOTICE REQUIRED FOR PSPECTIONS—PLEASE CALL(209)953 7697 SIGNED ti TITLE DATE (P JO O IN O N RO ME TAL DEPARTMENT USE ONLY '7 Application Accepted BY Date-3/310 3 Area JL4 Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit 31gq Pump Inspection By 1 ,1 / Date 13 WAIVER Received %% Destruction Inspection By V V• N 61 Date t4-q- D,� Constructed Well Depth It COMMENTS PE SC ReceivedAmount Dale Permit/ Invoice# WdI 1D# Codes Info B ash Remitted Service Re uest# 3 32-7-T mp 0o u EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002