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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR I.)"PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESSC �]C'I]TY/ZIP/� r, CROSS STREET �i�..1 1 �'•'C API OOI (r 0-Lo -3 0. UL f i ) PARCEL SIZE OWNER NAME 1�I /S�Uf I"L f p S'1 T//(. tS PHONE OWNERADDRESS � SteI' A Ip CITY/STATE/ZIP CONTRACTOR "( C S SQG PHONE !•3Y. 7-7 F —Sir-(AI IUN CR CONTRACTOR ` Z f..� O 1� i SUBCONTRACTOR PHONE j SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 1 GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section Q` INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charsctenzapon to ❑Public Water System - �• Vdiffemntfmm — W.w,Syiirem .— ..lett .—Ph—N—ber TYp6 OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole Other mbar of..It, number of borings number of borings 1 ❑Monitoring Well(s) u ° ❑Soil Borings) ❑Geotechnical , ❑Well Destruction ❑OutOf--Service Well ❑Out-Of-Service Well Renewal Cl New Pump ❑Pump 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 O Open Bottom ❑Gravel Pack/Gravel Size in diameter f ❑Conductor Casing in diameter / Conductor Casing Depth I.. ft Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other O Grout Seal Depth R ❑Neat Cement(94 Ib hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water T ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on Fite ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Box [3 Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set Il Standing Water Level it WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other 1 Wel]Diameter in Tota]Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ti Sealing Material ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20"/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on Fite ❑Spas Submined 1 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 J 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. MINIXUY 24n(I rINfS(PE(GCCTPIOlN<Sf-SP(LEASE CALL(209)953-7697 r -SIGNED NoCTITLE DATE 12 IC 1 i .T .. „� tl j 1, 1/ g 1 1 f 1 I 1 1 }BL N pl G Wit DEPARTMENT USE OFLY ^ Application Accepted By �IY Date tD Area Z Employee ID# Grout Inspection By t __ Date ❑ SPECIAL Well Permit f Pump Inspection By Date ❑ WAIVER Received 1 Destruction Inspection By Date Constructed Well Depth ft 1 COMMENTS ---- PE 'SC Received Check#/ Amount Date Permit/ Invoice# Well , Codes Info B Remitted Service Request# 22 21 161 S17103 SK0033 10-10 ' zs�7-)L- rs ' '