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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Gam/tTMENT 304 E WEBER, 3-FBecK ( 9)468-3420 1U NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRYEAR FROM DATE ISSUED oj IP— JOB ADDRESS /�/ )wr—_ APN CITY/ZIP /'�`�^-'/V" v / y U T MI PARCEL SIZE F CROSS STREET 9672- 0`�� - OWNER NAME AJ /(�1 � `-"'' �(^d �"v a PHONE ~V n OWNER ADDRESS I D 00 , LC CCITY/STATE/ZIPex C J 5 7�-2 CONTRACTOR nf PHONE 1 - -2- .`/z- V / CONTRACTOR ADDRESS L CITY/STATE/ZIP 61 � ' ( F7 SUBCONTRACTOR �/ PHONE ' {I ^-' Q SUBCONTRACTOR ADDRESS /V /,ft' CITY/STATE/ZIP N LICENSE -3657 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATEC I GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sarnpling/Characterization ❑Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE Or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) ❑Soil Boring(s)number of wells number of borings Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Servia Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION �[ Drilling Method ❑Mud Rotary ❑Air Rotary DY Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth S ft Excavation / 0 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in ThicknyNleat auge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth S—ft Cement(94 lb bub/5-/0 gal water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(20%solids) Manufacturer Spec%solids % Name ❑Specs oil File ❑Specs Submitted Grout Placement Method Pumped lee Fall ❑Othe etardant/Accelerator(name) PEDESTALJAC Installed By ❑Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level tt WELL DesTRu 10N ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Ne Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from ftto ft Sealin I ❑Neat Cement(94 lb bug/5-10 gal water) ❑Sand Cement suck 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 ft below grade ❑Complete to Existing Surface Pad 1 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 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKER COMPDn'rEENSATION LAWS. J1 NIMUM 24 HOUR ADVANCE NOT ' REQUIRE --7FOR INSPECTIONS SIGNE V TITLE t�.t �Cl�-C��JI O t V P � Ixt- lot P E -- — f DEPAf.�":EN`T Us ONLY Application Accepted By L Date Area Employee ID#C � Grout Inspection By✓ i i Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth i It COMMENTS PE SC Amount C eek Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Service Request# -9-3 0 o x'00 3f67 EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002