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WELL/PUMP PERMIT SAN JOAQUIN COVNTY ENVIRONMENTAL HEALTH DEPARTAIEW 304 E WEBER AVE 3"FL-STOCKTON CA 95202-(209)460.3420 NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED f ;fin, rn JOBAbDRESS + O tc^I r[JIV CITyrLip ren 9 0 CROSS STREET APN � PARCEL SIZE� A OWNERNAM£ y�y n PHONE L OWNER ADDRESS �Ct� N 1C�� ,��, ,,,,,,_ CITYISTATElL1P CONTRACTOR L PHONE CONTRACI'ORADDRESS '�'^.� ! CITYISTATEMP I ', SUBCONTRACTOR PIIONE SUBCONTRACTOR ADDRESS CITYWATEfLir 1 Wcense 13C-57 ❑C-61 ❑D-09 ❑Other NI7NEBEa EXPIRATION DATE (� CEOCRAPHICALINFORMAT": Coordinates X Y Township Rangc Saclien 1 INTENDED USX mcsticlPrivale ❑Irrigation/Agricuhural 13 industrial 0 Water Quality Monitoring Q Soil Sampling/Charaeleri7ation k ❑Public WaterSyStem ' Ifdiffrn:m from Owner: aw yrtem ame nrec�. arse or w,e u r TYPE OF WORK aw Well ❑Replacement Wel( 0 Wall Alteration/Modification 0 Test Hole ❑Other 0 Monitoring Wells) numbcraf"Its C7 Set Boring(s) numberarbormip ❑Geotechnical ^rmberafaonng 0 Well Destruction ❑Out-OF-Service Well ❑Oul-O&Service Well Renewal O New Pump ❑Pump Replacement 0 Pump Repair ❑Cross-Connection Itcpair WELL Coi im umor�44 Drilling Method EI-Mud Rotary 17 Air Rotary ❑Auger ❑Cable Tont O Push Point ❑Other Proposed Well Depth-.2jO A Escavaiion_ in diameter 0 open Bottom Q410vel Pack I Gravel Size J"in diameter ❑Conductor Casing in diameter I Conductor Casing Depth tt Well Casing Diameter-J�-in ThicknesslGougefASTM Schad Q 0 Steel I9'FrRstic ❑Stainloas Steel O Other Crout Seal Depth JJW fl ❑Neat Cement(94th bag/3-lOgal water) 0 Sand Cement suck raix17 gal water 17<ntonite(20%solids) 0 Manufacturer Spec%solida_24�!_% Q-55ecs On Fite ❑Specs Submitted Grout Placement Method limped ❑Free Fall 0 Other 0 Retardant I Acaelemior(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor Ther ❑Concrete Pedestal Dimensions: Width R Length_12 Thick in ❑Christy Bax 0 Stove Pipe PUMP 0 Submersible 0 Turbine .Q Other HP PUMPSel R Standing Water Leve t R ., WELL DEsrRUCrION 0 Open Bottom 0 Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth R Depth m Water ft 0 Casing to be Perroralcd From It to a Sealing Material (3 Neal Cement(94 lh hrig/340 gal waler) ❑Sand Cement sack rnix 17 gat water Cl Bentonite Pellets ❑Bentonitc(20%solids) El M43facturer Spec e/solids_% Name ❑Specs on File ❑Specs Submiltcd Placement Method 0 Pumped ❑Free Fall CI Other 0 Complete with Mushroom Cap 11 I)CIDIftradO Cl 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 1 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1-AM IN COMPLIANCE WITH ALL- WORKERS COMPENS TION LA [MUM 24 HOUR ADVANCE NOTICE UIR&D FO ECTIONS SIGNED TITLE DATE UP A + r t 4 \` 5 AU 411':s a tj, t .. P PARTMENT US N4 q Application Accepfcl2y Rate Y Area 2'[p Employee Orous Inspection B - - Dato `�`� 17—SPECIAL W01-Permit Pump Inspection 8 Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth R COMMENTS PE SC Amount Chrcklt! Received Date Codes Info Remitted as B rvlce R uert Inv6itt p, Well IDIf ! 3 a paZ EHD43-02.006 51712002 MASTER WATER WELL PERMIT