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''YELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEMENT 304 E WEBER A\aot°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED /?O/ .� rn < IVj1 1R rc��l (�.. C- ItC/" ' CITY/ZIP r/►�.W�OL, C� • ��3 JOB ADDRESS .�._ r t -r C 11 %'�.�-L PARCEL SIZE _LAND USE APPLICATION# 70 CROSS STRF.E y OWNER NAME (t1,Y ! "� {�t�llC-�C�O P/HJONEe'd C� D) 'go-q-3460 �Jy OWNER ADDRESS ,l (-1�)1 J / /r Ic� _ CITY/STATE/ZIP �VIC�t•Jee - ` CON'T'RA(-I.OR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CI I'Y/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 ❑Irrigation/Agricultural 9i Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System ,d/D f � �JPR,)lJ LeZ Z ((different from owner: -water ystem Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well Well Alteration/Modification ❑Test Hole ❑Other 13 Monitoring Well(s) _#of wells ❑Soil Boring(s) n ofborings ❑Geotechnical a of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Purnp Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth t't Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl Well('Using Diameter in ThicknessA iauge/ASTM Sched _ ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout tical Depth_ It ❑Neal Cement(94 11)hag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name O Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other J ❑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 WILL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to It Sealing Material 11Neat Cement(941h hug/5-10 gat water) 13Sand Cement sack mix/7 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 1 HEREBY CERTIFY THAT I HAV PREPARED T APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE STATE LAWS AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WI E CA OR A CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSA S. N NIM 1;2 DVANCE NOTICEREQUIRED FOR INSPECTIONS/ O SIGNED /y ` TITLE �/V A4,n DATE �J� r 1 I r ' 1 t UI CCiUN GtJ EPARTMENT U ONLY,/ �—jf�, Application Accepted By 30 Date d Area---' Employee ID# 1 yu tJ Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date 7/ 71A ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft w ed l Al /j //_ �' p COMMENTS i4 /a .S/.r 1,e_- L1/,11 6e (�dlGf� T O IrtAl � /T �/� t" OV�. /OwY��GI't.' PE SC Received Amount ate Permit/ Invoice# Well IDN Codes Info B Cash Remitted Service Request# j S�c Ca EHD 43-02-006 MASTER WATER WELL PERMIT 12,22/2003