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pull 1 ;c- um ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAk' i.TI:NT �i 304 E WEBER AVE.1-�FL-STOCKTON CA 95202 - (209)468-3420 NO I-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED X — — n rn JOB ODRESS 11 t� CITY/ZIP 1, l? CROSS STREET �1�/� 7)I� APN 60-5 PARCEL SIZE ? tv A S ►� OWNER NAME 6. r PHONE OWNER ADDRESS J / W 'P CITY/STATE/ZIP � al/ CONTRACTOR rl N PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE (� SUBCONTRACTOR ADDRESS CITY/STATE//ZIP LICENSE C-57 A-IC-61 ❑D-09 ❑Other NUMBER � IT59� EXPIRATION DATE T GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑In strial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Public Water System t?��(�(/, �SL- If different from Owner: ater System ame ontact ame or one um er TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) 1:1 Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of=Service Well Renewal New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCT.ION Drilling MethodMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth. ft Excavation� in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schede ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth /be) ft ❑Neat Cement(94 Ih hub/5-10 ba!water)((((�? Sand C ment I ,,� .pack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % iqt C� h � �Specs on File ❑Specs Submitted Grout Placement Method PIK.--ped ❑Free Fall ❑Other ❑Retardant/Accelerat (name) PEDESTAL Installed By )<Driller ❑Pump Intractor ❑Other Concrete Pedestal Dimensions: Width. ft Length ft Thick TO in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP Pump Set_/''j6(:�_ tt Standing Water Level --eo 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(941b bag/5-10 gal water) ❑Sand 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 I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI HOU DVrA��wN--CE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 z SIGNED - C�y` vv�— TITLE T�/IyIll � DATE �1ITIL �l t fy I 11-T I IV U<� Uli C L S `{ f\\JI . DEPARTMENT iSE ONLY 1, Application Accepted By rJ I v 0-' Date o '" �—n� Arca Employee ID# G-7 Grout Inspection By I-N- N(l) Date ^6—c53 ❑ SPECIAL Well Permit Pump Inspection By W NGI Date C7'2C7-�� ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth R COMMENTS PE SC Received Che Amount Date Permit/ Invojce# Well ID# Codes Info By Cash Remitted Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002