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WELL/PUMP PERMIT, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95242-(209)468-34ze t• NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP Xipew re7r• 9s3G L y L APN �� © O—�OeS I.f•S�j � CROSS STREET �/ ! PARCEL OtiVNERNI.ME A) 4T A-I.el�Sfofy PHONE OWNFRADDRr$$ _Z�_ � Z +ne`�.•- C—/STATE/ZIP 1 CONTRALTGR - Mejr! PHONE CONTRACTORADDRESS kY )21a1'q •] Jam. CITYISTATE/ZIP $Arty , 4• SUBCONTRACTOR .SJ PHONE_ _ O SUBCONTRACTOR ADDRESS - CLTVISTATE(LIP ic>q LICENSE ❑C-57 ❑C-61 ❑D.09 Cl Other G�rJ NUMBER z-- EXPIRATION DATE GPOCRAPHICAL INFORMATION: Coordinates X Y Township Range Seelion INTENDED DSE mastic/Private ❑Irrigalion/Agricullura] ❑Industrial ❑Water Quality Monitoring O Soil Sampling/Characterizetion Cl Public Water System j f lfdityc=trrom Owner: neer ysrem ame vnraer eawm ne um r F TYPE OF WORK ❑New Well ❑Replacement Well 13 Well Alscnidon/Modifieation 0 Test Hole ❑Other Z4- number of welis nuher of bo ❑Monitoring Well(s) 13 Soil Boring(s) mn� O Geotechnical rurmbcrofhoreryp 6N1 0 Well Destruction ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Dril Iing Method 0 Mud Rotary I7 Air Rotary ❑Auger CI Cable Toci ❑Push Point ❑Other . Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter ❑Conductor Casing in diameter 1 Conducwr Casing Depth R Well Casing Diameter in Thickness/Gausc/ASTM Schad ❑Steel Q Plastic ❑Stainless Steel ❑Other I Grout Seal Depth it f7 Neat Cement 416 P (9 hag I S-10gu!"ter) 13 Sand Cement sack rn7x J7 gal ware[ ' ❑Bentonite(20%solids) (3 Manufacturer Spec%solids_% Name O Specs on File ❑Spas Submitted Grout Placement Method ❑Pumped ❑Free Fell Q Other ❑Retardant I Accelerator(name) PEDESTAL Installed Br ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width fl Length it Thick in ❑Christy Box ❑Stave Pipe PUMP %submersible 0 Turbine ❑Other HP1 Z� Pump Set ga fl Standing Water Level fl WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncascd Ll Other Well Diameter in Tota]Depth R Depth to Waler it O Casing to be Perforated from R to R Sealing Material ❑Neat Cement(941h hug/5-10ga1 mrrr) O Sand Cement jack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Subm4Led Placement Method ❑Pumped ❑Free Fail ❑Other ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad l I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W1TH SAN JOAQUIN COUNTY ORDINANCES,_STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MV REQUIREb LICENSE IS CURRENT AND ACTIVE WITH HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION MUNI 24 HOUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS +� SIGNED Y/ TITLE 'ry Q'�-_ DATE 7. 31S yp Ly Lt aS R DEPARTMENT USE ONLY '} Application Accepted BY Date 401-29-493 Area �f b Employee ID# 9374, Grout Inspection ByDatc 13SPECIAL Well Permit �— Pump Inspection By De 0 WAIVER Received , Deatmvlion Inspection By Ole Constructed Well Depth fl COMMENTS PE SC Amount heck#/ Reeelvetl PermlV Codes Info Remitted as B Date Service Re uest# Invoice# Well 1119 EMD 43-02-006 SnP-002 MASTER WATER WELL PERMIT f