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W Euu / rUlvir rL' Itivll I SAN JOAQUIN COUNT\ ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"u FL-STOCKTON CA 95202 - (209)468-3420 ,..NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED U. JOB ADDRESS �7 C��I J ` CI`TI'/Z�I'}P GCI( > (� L5 CROSS STREET J �((�1i1 t APN Q PARCEL SIZE J �� TOWNER NAME Do PHONE OWNER ADDRESS 41' V v J 1 N t� 1\ CITY/STATE/ZIP C�� 1 TCONTRACTOR l i\� 1 PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP T SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP L 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 wrier: ater ystem 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 Xut-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair C'!1 WELL,CONSTRUCTION t - 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 hag/5-10 gal water) ❑Sand Cement suck 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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe TWEL,,cDFSTRUCT'ON P ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth tt Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb hug/5-10gal water) ❑Sand Cement .tuck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIM 4 HOUR ADVAN NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SI ED TITLE DATE �\ J