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� lWELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dt1yn MENT 304E WEBER ANInd°n FL-STOCKTON CA 95202 - (209)465-3420 NON-REFUNDABLE PERMIT /,[) CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED tn //007Co f/ J / -645f/%PO.,4g, ,W- CITU/ZIP LO CL/ e4. • /SZSFo JOB ADDRESS /� Y CROSS STREET / S /y11C E /C.IZ- APN r� 5q-� '�/ PARCEL SIZE 69 a 1 A � PH/ON1n,r -3(OWNER NAME OWNERADDRESS �Z60C/ ,.44 i!51 CITV/STATE/ZIP CONTRACTOR "PHONE 7/yiZ �J'�J� Q CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section INTENDED USE ❑Domestic/Private ❑Ifrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization ❑Public Water System Ifdifferent from Owner: Water S,stnrn Name C..tact N.me or P F.ai -.mer TYPE OF WORK ❑New Well ❑Replacement Well Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells 0Soil Boring(s) numberoft,...g, ❑Geotechnical "a'n1nnr0flwrings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Plump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary Cl Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth it Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _in ThickneWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth fl ❑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 ElPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑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 it Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑SpecsSubmitted Placement Method ❑Pumped 0 Free Fall ❑Other ❑Complete with Mushroom Cap It 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. I 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. y Mljllf�1U 4 HOU�+ADV j�7CE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)91r533--77697 SIGNED TITLE Dtn *T- C. T C. The well must be repaired under permit and inspection by the Environm IVISion (San Joaquin County Development Title, Section 9-1115.4(e)) as follows: 1. Install cement surface seal around the well casing to protect the well casing sufficiently and the integrity of well grout. Z. Provide sample tap prior to pressure tank. F&M Page 1 of 2 ^ �A Division of San Joaquin County Health Care Services Application Accepted By�// Date //U?o� Area t-(If Employee ID# 7'171 Grout `IT7Grout Inspectio Date [3 SPECIAL Well Permit v1gj Pump inspect' n B Date5�-� �l ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COM EJJTS E SC Received Che ck#/ Amount Perm Date iU Invoice# W I Codes Info B as Remitted Service Re nest# -��r EHD 43-02-006 JJ MASTER WATER WELL PERMIT 12/6/2002