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(') WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH—iXARTMENT 304 E WEBf --a'E 3"0 FL-STOCKTON CA 95202 - (209)468-3420 CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED NON-REFUNDABLE PERMIT �] �1 J CITYIZiP d FSTREET aa-- !9A1 { M 7— 3-3 AP Z� l q� q _PARCEL SIZE LAND USE APPLICATION#_ — o C-" ` / ) 92- 1 � �! PHONE //, t. r"� �- CITYI$TATEJZIP OWNER ADDRESS t PHONE 1 c..�1 f 1 ` CONTRACTOR _ r JI _ _ CONTRACTOR ADDRESS CE-TY/STATE/ZIP._�S_ YYY Vvv PHONE SUBCONTRACTOR CITY/STATE/ZIP SUBCONTRACTOR ADDRESS ^ j r LICENSE ❑C-57 ❑C-bl ❑D-09 [3 Other NUMBER r1) XP[RATIONDATE � ©�./ Township Range Section GEOGRAPHICAL INFORMATION; Coordinates X INTENDED USE `Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Water stem ame ontact ame or one um er If different from Owner: Sy Stern OF WORK C]New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other a ofborings #of borings ❑Geotechnical ❑Monitoring Well(s) #of wells ❑Soil Boring(s) ❑Well Destruction ❑Out-Of-Service Well [3 Out-Of-Service Well Renewal ❑New Pump ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft l Well Casing Diameter in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sea] Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water w ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Cl co Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant i Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other 13 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pie PUMP Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Seating Material 0 Neat Cement(941b bag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑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 REGULATIONS. 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. MIM 24 HOUR A VANCE NOTICE U RED F INSPECTIONS SIGNE TITLE / ATE 'I /I .0v ON fy EN AL P .R - DEPARTMENT USE ONLY .j- Application Accepted By _ Date 3 U4 Area � Employee 1D# e1 ?y q, Grout Inspection By Date ❑ SPECIAL Well Permit / F Pump inspection By Date (r' " ``1 11 WAIVER Received p Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received C C eck#1 Amount 11 Date Permit! Invoice# Well ID# Codes Info By —CE-ill Remitted Service Re nest# EHD 43-02-00h MASTER WATER WELL PERMIT 1 V22/2003