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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL FIEALTH`...:PARTMENT 304 E WEBk.._.'vE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(249)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED FCROS / XC CITY/ZIP� Y' � 9G S RESS ! d I ,; A REET W � F � APN �f��PARCEL SIZE LAND USE APPLIC�A7TION# / y P PHONE OWNER NAME t G ,�rG,'C��S U' • OWNER ADDRESS / CITYISTATE/ZIP ✓L qr�+��/.. f PHONE d. G CONTRACTORi E �J' j&e26gs4o AC 9S-3S7 CONTRACTOR ADDRESS I I 'S 141 �� CITYISTATEIZIP PHONE SUBCONTRACTOR CITY/STATE/ZIP �} SUBCONTRACTOR ADDRESS LICENSE C-57 ❑ EXPIATION DATE C-61 ❑D-09 ❑Other NUMBS R , �� V GEOGRAPHICAL INFORMATION: Coordinates X y r Township Range Section =INTFNDEDE :OPu:blic ticlPr'tvate ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Water System ontaet ame or one um er rent From Owner. ater ystem ame TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other #ofl>orings "borings borings Cl Monitoring Wells) #of wells [3Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection R air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool [3 Push Point ❑Other Proposed Well Depth Z 20 ft Excavation .. /,Z in diameter ❑Open Bottom travel Pack/Gravel Size in diameter N ❑Conductor Casing in diameter 1 Conductor Casing Depth ft 1 Well Casing Diameter 0---in Thickness/(:iauge/ASTM Sched !�e ❑Steel )PQlastic ❑Stainless Steel ❑Other Grout Seal Depth--fes-ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method Xpumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed By Cl Driller /;Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe 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 Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) Cl Sand Cement sack mix/7 gal water Q 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 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED_L6 c-, Y N 1 TITLE 1NVLt1kW@A DATE ~' 1- 720 L54k-11 v hil A 777-1 Al A J AQ IN CO N H T D P T EN DEPARTMENT-USE ONL -,"Y_ _ � __e r�-� — �- •-G� Application Accepted By _ Date f L Area iC I� Employee ID# __�~. Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Receivedheck# Amount Date Permit! Invoice# Well ID# Codes Info B Cash Remitted Service Request# EHD '��43-02-006 / - �""'- yr ? WATER WELLPERMIT 12122/200 5`vy/li7 ; Zoe 'T 44147) Ai .Rc