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WL' LL 1 ruivlr ri:;Fuvill SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH "ARTMENT 304 E W£BF VE Va FL-STOCKTON CA 95202 - (209)465-3420 NON-REFUNDABLE PERMIT CALL 209 953•-7697 FOR INSPECTIONS ( .sXPIRES 1 YEAR FROM DATE ISSUED JOelAbiiliss 6 4 �� CITY/ZIP� a 4 P1 n CROSS STREET _ _ p APN 005-03o r ol PARCEL SIZE 11 OWNER NAME �f / PHONE OWNER ADDRESS /5 • �/ (ma y CITVISTATEIZIPYZ t+�y !!!! CONTRACTOR ` ' , PHONE 20?—?c T—C-2 7 1 CONTRACTOR ADDRESS jW�✓� %4 _ 1. CITYISTATE/ZIP SUBCONTRACTOR PRONE SUBCONTRACTOR ADDRESS CITYlSTATEIZIP G LICENSE ❑C-57 ❑C-61 M D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 0 Domestic/Private ❑Irrigation/Agricultural 0 Industrial t 0 Water Quality Monitoring 0 Soil SamplinglCharacterization 0 Public Water System if different from Owner; Waier System Name Contact Name or Phone Number if. TYPE OF WORK ❑New Well 0 Replacement Well ❑Well Alteration/Modification 0 Test Hole 0 Other 0 Monitoring Well(s) number of wens 0 Soil Boring(s) number of borings O Geotechnical number of borings D Well Destruction ❑Out-Of-Service Well' ❑ ut-Of-Service Well Renewal ❑New Pum 0 Pum Re lacement 0 Pum Repair Cross-Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool ❑Push Point 0.Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft ' Well Casing Diameter - in Thickness/Gauge/ASTM Sched ❑Steel , 0 Plastic ❑Stainless Steel 0 Other t,] Grout Seat Depth ft 0 Neat Cement(94 lb hag/5-10 gal wafer) 0 Sand Cement sack mix I7 gal water 0 Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs-on File 0 Specs Submitted Crout Placement Method ❑Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) PEDESTAL Installed_By ❑Driller 0 Pump Contractor 0 Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe PUMP 13 Submersible ❑Turbine 0 Other HP Pump Set ft Standing Water Level ti WELL DESTRUCTION ❑Open Bottom 0 Gravel Pack 0 Uncased ❑Other Well Diameter in Total Depth A Depth to Water ft .❑Casing to be Perforated from ft.to ft ^" Sealing Material 0 Neat Cement(94 lb hag 15-10 gal wafer) ❑Sand Cement suck in&17 gal water 0 Bentonite Pellets 0 Bentonite(20%solids) 0 Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted Placement Method ❑Pumped 0 Free Fall 0 Other 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN, JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RECULATIONS. 1 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 COMPENSATION LAWS. l MU 24 HOUR ADVANCE NOTICE REQUIRED PO INSPE T[ NS SIGNED r TITLE � DATE Q lid 69 VW%CbpC NR N5 A 1910N 0� DEPARTMENT.USE ONLY - `��AApiicationepTd' Area- _ l Employee 1D# Grout Inspection By Date © © SPECIAL Well Permit i Pump Inspection By Date 8`2��a L 0 WAIVER Received Destruction Inspection By Ua Date Constructed Well Depth ft COMMENTS � PE SC Amount Check#! Received Date ' Permitl Invoice# WellAD# Codes Info Remitted By Service Request# 1311 s 5'0 1 D15-- Zw-- 97RA7a-fTA-003d-11as a EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002 1 �