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W ELIE / Y UAir YLt MV►11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE�'MENT 304 E WEBER A .0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT .LL 209 953-7697 FOR INSPECTIONS IRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP f <br /> y <br /> CROSS STREET APN _ V� (7,9 PARCEL SIZEtv <br /> OWNER NAME <br /> OwNERADDRESS CITY/STATE/ZIP <br /> CONTRACTOR <br /> PHONE D <br /> CONTRACTOR ADDRESS CITYISTATEIZI P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADD CITYISTATEIZI P <br /> I <br /> LICENSE 0( 57 ❑C-61 ❑D-09 ❑Other NUMBER ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural. ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Q <br /> ❑Public Water System <br /> If different from Owner: Watier System Name Contact Name or Phone Nurn er <br /> TYPE Or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other j <br /> number of wells number of borings number of borings <br /> ❑Monitoring Well(s) 13 Soil Boring(s) 13 Geotechnical <br /> ❑Well Destruction Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Re liacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> i <br /> Proposed Well Depth tt Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gouge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other ,. <br /> Grout Seal Depth R ❑Neat Cement(94 lb hug/5-10 gal water) 0 Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> .Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑'Concrete Pedestal Dimensions: Width ft Length It Thick in ❑Christy Box ❑Stove Pipe ; <br /> F <br /> PUMP ❑'Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ti <br /> WELL DESTRUCTION Q Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> I I <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from—ft to ti � <br /> Seating Material D Neat Cement(941h hug/5-10 gal water) ❑Sand Cement sack mL 17 gal water ❑Bentonite Pellets <br /> ❑'Benta.tite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap It below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS i <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI 2Z.1 OU ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED3 <br /> TITLE lL7-�h n� .- .. DATE <br /> 1" CA <br /> �j fill <br /> I <br /> I <br /> O QU <br /> EN 1R f <br /> • <br /> ' EPARTMENT USE Y � <br /> Application Accepted By ate Area Employee IDH <br /> Grout Inspection By Date ❑ SP CIA I.Well Permit <br /> Pump Inspection By Date ❑ AIVER Received I <br /> Destruction Inspe ion By Date Constructed Well Depth ft <br /> COMMENTS — - co-i <br /> 2 i v r V <br /> PE Sti Amount chpckk Fteceived Permit/ j <br /> Codes Info 'd Remitted Cash BI Date Service Request# Invoice# Well # <br /> 179 00- DD <br /> EHD43-02-006 MASTER WATE11 WE LL.1'ERMI"I" <br /> 5/7/2002 <br />