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WELL / PUMP PERMIT Y SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTIi`rePARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 NO J-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB IDDRESS 1 l,�`'' J�( CITY/ZIP .. ++ tt��/Ci� / �.� / 3_. CROSS STREET � t �tq Q AW A N PN 0-5 0 / PARCEL SIZE OWNER NAME % PHO,N//(E� OWNER ADDRESS� / /��/ /` CITY/STATE/ZIP , '` l I V CONTRACTOR �/rA I 'C 4 f O I 1 1 1�1 /.�PF'IONE �2�]�, 1/ CONTRACTOR ADDRESS 1 CITY/STATE/ZIP 1 )(� l✓ -`F SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITQY�/(STTATE/ZIP LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER f�Ic EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑Irrigation/Ag/ric�ultural G❑In trial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Public Water S�stem !�✓�( d✓�� -1 If If, from caner: water System Name Contact Name or Phone um er 1 TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other r ❑Monitoring Well(s) number of wells ❑Soil Boring(s) numberofborinbs ❑Geotechnical numberofborinbs ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRU ION Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool 11 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 -X..�--in Thickness/Gauge/ASTM Sche ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib bug/5-10 gal water)((,(1, n. Sand C ment r) vack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % NSMe C/ 1 - ;❑Specs on File ❑Specs Submitted Grout Placement Method 01ru-tped ❑Free Fall ❑Other ❑Retardant/Accelerat (name) PEDESTAL Installed By I<Driller ❑Pump 'ontractor JIM ❑Other Concrete Pedestal Dimensions: Width ft Length i tt Thick in ❑Christy Box ❑Stove Pipe PUM11P Submersible ❑Turbine ❑Other HP Pump Sete tt Standing Water Level_._ tt 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 tt Sealing Material ❑Neat Cement(94 lb 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 tt 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. I 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 DVANCE NOTICE REQUIRED FOR �INSPECTIONS—PLEASE CALL(209)953-7697 SIGNED .. C TITLET ZN��-1 �1 I� DATERib' -31 I� OA UIQ C � S MS! , JDEPARTMENT SE ONLY , 75� Application Accepted By 1 " LN Date �0 "-2'd� Area Employee ID# J Grout Inspection By�aN N Date to—f,03 ❑ SPECIAL Well Permit Pump Inspection By�f� N�• Date S'25-0`� ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Che Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# qac � 5?,; .7j1 ;- ,o b �. s5�S5�5� EHD 43-02-006 MASTER WATER WELL PERMIT I�iFnnn�