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a -WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE*,,WMENT 304 E WEBER A, `°D FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPEC IONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS [ r [ =/�(r �^ �� CITY/ZIP �</ C�n.J G•J, a CROSS STREET / / [[' APN V 1'0 Z X Z PARCEL SIZE �7• �3 ��'� � OWNER NAME Z11q,I G Io Se, 7Z a I- PHONE •5��/-- "�(J G r�� OWNER ADDRESS / 7�( _ 1'`P CITY/STATE/ZIP S r (P l r �� ✓ V CONTRACTOR ` PHONE CONTRACTOR ADDRESS �� )?t 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 ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air R Lary ❑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 lb hub/5-10 gal water) ❑Sand Cement sack mix/7 gal water _r) ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted r Groul Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerahtr(name) PEDESTAL Installed B ❑Driller ❑Pump Contractor )ther =;,s 4-w(/ S u.c r f-v,-j S'CQ I {/) Concrete Pedestal Dimensions: Width ft Length tl Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level ft Wlad.DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in 'Total Depth It Depth to Witter _ 11 ❑Casing to be Perlbrated Trout 11 to tl Scaling Material ❑Neat Cement(94 lb hag/5-10gal water) ❑Sand Cement .rack 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 11 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 O CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI IMUM 4 HOUR A ANCE NOTICE REQUIRED FOR;INSPECTIONS-PLEASE CALL(209)953-7697 SIGNE 1 6 t TITLE C 'U ?7 11 DATE Lt S NN O 01J d0UN1j r_1 VII-UN%4L:NIA4L /� %J DEPARTMENT USE ONLY c� r� Application Accepted By 'd(l e Date 3 Z U Arca ZI Employee ID# (.3 7 1/O� Grout Inspection By Date ❑ SPECIAL Well Permit [/ 1 Pump Inspection By / Date ❑ WAIVER Received Destruction Inspection By Q I Date 4 Co tructed Well Depth ft COM ENT /LOQ • C — 0Z_ O c 7 PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B as Remitted Service Request# FS7 3-7 EHD 43-02-0q6 // / 1 _TER WATER WELL PERMIT 12/6/2002 q'1,091'I �T�rPi A 1/h^Irl� �?