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F1SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH i "RTMENT Y v+ `+ y yy4 304 E WEBS 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 2119 9533--7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED F, JOB ADDRESS C[TYIZIP� ! y CROSS STREET e j g APN 1005 —0 30 — O , PARCEL SIZE V OWNER NAME PHONE OWNERADDRESS /� r �/ !/1 y •� CITYISTATEIZIP -,40—f� rj E CONTRACTOR PHONE t CONTRACTOR ADDRESS 2W66F CITYJSTATEIZIP SUBCONTRACTOR PHONE E SUBCONTRACTOR ADDRESS CITYISTATEIZIP F# I LICENSE Cl C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE r I f GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water.System If different from weer: ater ystem ame ontacl ame or Phone Number :. TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other 13 Monitoring Well(s) number ofwekls ❑Soil Boring(s) number ofbarin6s ❑Geotechnical numbrrofborinyn C ❑Well Destruction ❑Out-Of-Service Well ❑ ut-Of-Service Well Ren ewal f. - ❑New Pump Pump Replacement ❑Pump Repair ros-Conection Repair 3:WELL CONSTRUCTION Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 'z D Conductor Casing in diameter 1 Conductor Casing Depth it 11 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel M Plastic' la Stainless Steel ❑Other C Grout Seal Depth ft ❑Neat Cement(941h hug/S-ldgal water) ❑Sand Cement suck rnix 17 gal water ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted —y Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) PEDESTAL Installed By ❑Driller 11 Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe I' Pump ❑Submersible ❑Turbine C1 Other HP Pump Set ft Standing Water Level 11 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth tl Depth to Water ft ❑Casing to be Perforated from ft to ft (^ Sealing Material ❑Neat Cement(941h bag/S-1Ogal water) ❑Sand Cement sack in&17 gal water ❑Bentonite Pellets ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other F4 ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad f 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— 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. 24 HOUR ADVANCE NOTICE ®�IN�SPrE Tf�NS' �+ SIGNED TITLE ��,�„' �d�o DATE �c3 QL Y € as FJ � ly v n f v