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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 104 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> L^ m <br /> J09 ADDRESS V � � C1TYlZ1P_ ed - - - v <br /> t3 ? <br /> CROSS STREET APN PARCELSIaE <br /> OWNER NAME � rn PPHONE `Y 7 <br /> OWNER ADDRESS 'ZO/(+ J,,. }rte F <br /> CONTRACTOR ��`f Pilot, Gl(! �r T->'^�Y <br /> CONTRACTORADDRFAS L/C 16�! CITYISTATEIZIP r 0� <br /> PI10Nfi <br /> SUBCONTRACTOR�. <br /> SUBCONTRACTOR ADDRESS CI'1'VISTATEIZIP <br /> LICENSE U C-57 U C-61 ❑D-09 ❑Other NuMaeR EXPIRATION DATE �- <br /> GEOGRAPHICALINFORMATiON: Coordinates X Y Township Runge Section <br /> [NTEN DED USE 11DomcsliclPrivitc l7 lrrigalion/Agrieuhural ❑industrial 17 Water Qua lity Monituring ❑Soil SamplinglCharaclerizaiion <br /> ❑Public Water Clem onuKr amror one u r <br /> Irdifr—from wacr: m« ysrcm N.Mc <br /> TYPEOF WORK ❑New Well ❑R-p)aaement Well 0 Well Alteration/Modification ❑Test Hole 0 Cthcr number ufhnnny� <br /> umborurwalls ❑Soilnortn s nuntlxsurbormgi L]Gmuchrical I(—` <br /> O Monitoring W01(s)�_ Sl] <br /> U Weii Destruction 13 Out-Of-Service Well ❑ UE- -Service Well Renewal fes' <br /> ❑New Pum ❑Pump Reolacement ❑Pum R air Cross-COnneraion R <br /> WELL CONSTRUi <br /> N K5 <br /> Drining Method Mud Rotary ❑Air ROtary Q Auger ❑Cable Tool ❑Push Point D Other <br /> Proposed W01pth 11 ERcaystion in diameter ❑Open Bottom Q Gravel Pack I Gravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth It <br /> Well Casingiameter in ThicknesslGaugdASTM Sched_. ❑Sleet ❑Ptrstic ❑Stainless Sleet ❑Other <br /> i� <br /> Groul Seal epth 4 O Neat Cement(94!h hug 13-1 D go[wale) Q Sand Cement xut*mix 17 gel water i <br /> ❑Ben tonite(20°/solids) ❑ManuracturcrSpec%solids °! Name ❑SpecsonPile ❑SpecsSubmined -z <br /> Grout Placement Method ❑Pumped ❑Tree Fall U Other ❑Retardant t Accelerator{name) 0 <br /> PEDESTAL Installed BY Cl Driller ❑Pump Comractar Q Other <br /> ❑Concrete Pedestal Dimensions: Width Widt _t1 Length 11 Thick in ❑Christy Box [I Stove Pipe <br /> PVMP ❑Submersible ❑Turbine ❑Other_ HP_ Pump Set A Standing Water Level 11 <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well diameter in Total Dcpth tl Depth to Water 15 ❑Casing Lobe Performed rrom Il to 11 <br /> Se.hng M.teri.l ❑Ncat Cement(94!h hug15-10 gal,vale) ❑Sand Cement sacA mrr 17 gal wale [I <br /> ❑Brn[on it Pellets <br /> U 9entonite(20°1 solids) ❑Manufacturer Spec%solids_._% Name Q Specs on Pile U Specs Submiued <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap it below grade ❑Complete to Existing Sud'acc Pad <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TUAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> E is <br /> CURRENT AODACTIVE TH THE CALI ORNIA CONTRACTORS STATE LICENSE R <br /> BO DOI <br /> AND THAT I AM IN COMFY THAT MY PLIANCE WITED H ALL <br /> WORKERS COMPENSATION LAWS, <br /> I MU 24 HOUR ADVANCE NOTICE REQUIRED F01INSYE I NS <br /> SIGNED <br /> TITLE !l/I d'fl DATE X&VD <br /> N <br /> a '. c S J1 �gtitir~ <br /> ��r� DEPARTMENT USE ONLY r r t. GLI <br /> Application Accepted By <br /> Date Area— <br /> Ww' —('-ICY-- EmplOyeeIDJJ_ r1 f <br /> Grout Inspection By Dale l7 SPECIAL Well Pet-mit <br /> Pump Inspection By <br /> Date �j x;_a ❑ WAIVER Received <br /> Dale---- Construcitd Well Doplh <br /> Destruclien Inspection By --- <br /> COMM£NTS_'-��•o �l8 PRo? <br /> Check#! Received pate Permli7 <br /> PE SC Amount S uest# Invoice# Well lDy <br /> Codes Info Remitted Rv <br /> Z 5 9'0 r 2ti 1! LXx I <br /> MASTER WATER WELL PERMIT <br /> EHD 43.02.006 <br />