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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Di. ZTMENT 304 E WEBER3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ✓ 1 " ' CITY/ZIP I ► ( ,(,(, pO . P CROSS STREET APN �"13 2-0-6--(V P ,(� ARCEL SIZE ,�s'7vuS OWNER NAME \/r 1 PFiO " OWNER ADDRESS �J1 f I CITY/STATE/ZIP Li CONTRACTOR01-31 aC� L I L Su o CONTRACTOR ADDRE S I CITY/STATE/ZIP i 'J SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ' 1 CITY/STATE/ZIP LICENSE ❑C-57 4-61 ❑D-09 Other V/l NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section ' INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization n ❑Public Water System If different from Owner. ater ystem Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(S) number of borings ❑Geotechnical number of borings Cl Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump Xpump Replacement ❑Pump Repair ❑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 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib bug/5-10 gal water) ❑Sand Cement .tuck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width It Length ft Thick ❑Christy Box ❑Stove Pipe PUMP 9�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 tt to ft Sealing Material ❑Neat Cement(94 lb hug/5-10 gal wuter) ❑Sand Cement suck 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 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. 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. IMUM 24 OUR AANCE NOTICE REQUIRED FO INSPECTIONS-PLEASE CALL(2 09)/953 -7697 rTmaz-wTITLE ff�moeLATESIGNED EV A JI PC CJ IN O F 1'Al ME 1TN DIM 10 +1 —F--Ff J DEPARTMENT USE ONLY 14 Application Accepted By `� Date jr��a Area Employee IDti Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date / —�/� ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check# Amount Date Permit/ Invoice# Well ID# Codes Info By ash Remitted Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002