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' wELL/PUMP PERMIT SAN JOAQUIN COUNty ENVIRONMENrnLTH DEPARTMENT 304 E WEBER AVE 31W STOCKTON 3 .-NON-REFUNDABLE PERMIT CALL 249 953-7697 FOR INSPECTIONS PIN, .S 1 YEAR I > JOB ApDR 5SS z W Clrv(LIP n Y f� l 00 e 7 CROSSSTREET APN PARCEL SIZE / �f 8 G! OWNER NAME &BS/yyI L' ^�—N/R'1� - PHONE 3 7 '? OWNER ADDRESS I `�"a 40 J CITYISTATPJLIP e s'H4 a CorrrRACTOR �i1/'{5 / �i?s '/�� Puone CONTRACTOR ADDRESS elz � e'l`__ f�� Cil YISrATEMP -/", 47 SUBCONTRACTOR P]H)NE SUBCONTRACTOR ADDRESS CITYISTATEIZIP U S LICENSE ❑C-57 Q C-61 ❑D-09 her 2 NUMBER EXPIRATION DATE I— GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section INTENDED USE mestic/PrivaLe ❑IrrigatioWAgricuhural 0 industrial 13 Water Quality Monitoring 0 Soil SamplinglCharaelerization ❑Public Water System - Ifdiffer iWmO—n . W.,or Yuem mom -tact No=w N,nobu TYPEOF WORN O New Well I]Replacement Well ❑Well Alteration/Modification 0 Test Hole ❑Other - �r ❑Monitoring Well(s) nutnberorwells ❑Soil Boring(s) ^umberofboeinp p Geotechnical numberorlonnsa Q Well Destruction C]Out-Or--Service Well ❑Out-Of--Service Well Renewal 0 New Pump, I;nmp Replacement E]Pump Repair 0 Cross-Connection Repair WELL CONSTRUCTION ' Drilling Method 0 Mud Rotary, 0 Air Rotary 0 Auger ❑Cubic Tool EJ Push Point 13 Other Proposed Well Depth R Excavation in diameter D Open Bottom ❑Gravel Pack I Gravel Size in diameter O Conductor Casing in diameter I Conductor Casing Depth R Well Casing Diameter_in Thickness/0aug0ASTM Schell E]Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 0 ❑Neat Cement(941h hag l J-l0gof roarer) 0 Sand Cement .eack mix/7 Sal water ❑Bentonite(201/.solids) ❑Manufacturer Spec%solids_% Name ❑Specs on Fik E3 Spees Submitted Grout Placement Method ❑Pumped 0 Free Fall 0 Other O Retardant/Accelerator(name) PEDESTAL installed By ❑Driller D Pump Contractor 0 Other ❑Concrete Pedestal Dimensions: Width_ft length_ft Thick in ❑Christy Bos ❑Stove Pipe PUMP .JB'Submersible OTurbine -11 Other HP_ — PumpSet_4C;LQ R Standing Water level it WELL DESTRUCTION ❑Open Bottom 17 Gravel Pack ❑Uncased Q Otho Well Diameter in Total Depth 4 Depth to Water It ❑Casing to be Perfarated t-rmn It to 4 Sealing Material O Neat Cement(W 1h hug 15-10 gat water) 17 Sand Cement sack mix/7 gal water ❑Bentonile Pellets ❑Bentonite(20%solids) Cl Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 0 Free Fall ❑Other ❑Complexe with Mushroom Cap It below grade 0 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. 24 HOUR ADVANCE NOTIr}�'p�/J`'�Q�U,I6p��D FOR INSPECTIONS SIGNED TI1r1E 1 ��Y `� DATE ,L Ik IT DM _ --{�DEP TMENT USE�O Y J � F- r� Application Accepted By ��y` ')` =V Dae -rr{�`_`3 Arca 2 {� Employee IDtI Grout inspection By Date EI SPECIAL Well Permit Pump InspectionBy Date ❑ WAIVER Received Destruction Inspection y Date Constructed Well Depth It COMMENTS PE SC Amount heck# Received Date permit! involve# Well[Dp Codes Info Remitted Cas By Service Request# - •�' 5G% 1 4laD L6 "yg/oa, HHD 43.02-M MASTER WATER WELL PERMIT 5nrzoa2