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' r--YELL / PUMP PERMIT SAN JO UIN OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-i"'FL-STOCKTON CA 95202 - (209)468-3420 NON- FU ABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED s ,� _ M JOB ADDRE r � CITY/ZIP a CROSS STREETAPN ��b� PARCEL SIZEAbVAI •" ,�� OWNER NAME f PHONE S "2— 1733 y OWNER ADDRESS gag 4` �ti .� CITY/STATE/ZIP 5) (Jr tejtollj h I CONTRACTOR PHONE CONTRACTOR ADDRESS CITYISTATFJ'ZIP SUBCONTRACTOR PHONE SUhCONTRACTOR ADDRESS CITY/STATE/ZIP \ LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range 5cctlon IN'1'F:NIIF.I1 USF: ❑DJbliC caPrlvate stionlAgricullu�u� � ❑Industrial O Witter Quality Manitc>rijtg ❑Soil Sampling/CharnclerirAtion ❑Puhlic Water 5yslcm '��1. .. Irdil'rrrew frmn f iwnor: nicr yFtrin erne ('unluei-Nunir'ii�linar um rr I'YI%OF WORK ❑New Well ❑Replacemcnl Well ❑Well Alteration/Modification ❑Test i tole ❑Other ❑MOrtitorin Well(s) nwnber of wells number of borings number o!burin+s B O ❑Soil Borings} ❑Geotechnical t ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ross-Connection Repair I WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool 0 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 Cl Steel ❑Plastic ❑Stainless Steel ❑Other :s Grout Seal Depth ft ❑Neat Cement(94!h hug1540gal water) ❑Sand Cement sack mix!7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Gr6ut Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator{name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other I ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbinc ❑Other HP Pump Set ti Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack O Uncased ❑Other j Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to tl l9 9ealing Materlat 13 Neat Cement(94 lh hag/S-1D ga!water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 03 Specs on File 0 Specs Submitted Placement Method ❑Pumped ❑Free Fall 0 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 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. e9 M UM H ADVANCE NOTICE REQUIRED FONR INSP�EyCTION — PLEASE CALL(209)953-7697 SIGNED TTt'Lk: /Jl DATE r I i7 .r P JO SN pIV 4 Ny N� DEPARTMENT ISE Ory Ali nplication Accepted By ` Date `� �� Area Employee IDI! 4L2/13� Grout Inspection By lhtte I_ ❑ 1'[;CIA1.WCII PCI•mlt y Pump inspection By �11;1Date Q T ❑ WAIVER Received I Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received-1 Check#1 Amount Date Permit! Invoice# WeIl1D# Codes Info 8 as 1 Remitted Service Request# lOW 0 6 0 o lf6'03� l! HHD 43-02-D06 MASTER WATER WELL PERMIT f 2/6/2002 14