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VELL 1 PUMP PERMIT � SAN JOAQUIN COUNTY ENVIKONMF;N'1'AI.HEALTII DF:P,, dF:N'I' :104 E WEBER A'; .FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT j CALL. 209)953-7697 FOR INSPECTIONS EXPIRES I.YEAR FROM DATE ISSUED rA JOB ADDRESS O r CITY/ZIP z/ / Y P L ;��,,,r /fin D r e�wl m PN V 7 2- D 00 1 CROSS STREET PARCEL SIZE OWNER NAMEmz� PHONE OWNER ADDRESS CITYISTATEIZIP CONTRACTOR ^ PHONE9 10-6:1p�9.gz CONTRACTOR ADDRESS�/rJrJ � /�L!/z— CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYIIISTATEIZIP LICENSE G57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE ��D GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range- •Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agdculturai ❑Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization 13 Public Water System If different from Owner: Water ys(em Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification 0 Test Hole 0 Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Barings) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-01=Service Well Renewal ❑New Pump ❑Pump Replacement ❑Purnp Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter Cl 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 lb hag/5-10go]water) ❑Sand Cement sack mix/7 gal water 0 Bentonite(200/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 13 Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed BY 0 Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width f2 Length fi Thick in ❑Christy Boz 0 Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level ft WELL DESTRUCTION O en Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diamet' _ ,in Total Depth_ a v tt Depth to Water n ❑Casing to be Perforated from 0 R to 1.Ad 11 Scaling Material ❑Neat C ment(94 lb hub/5-10 gal water) an ement .rack mix/7 gal water 0 Bentonite Pellets Iii Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 13 Specs Submitted Placement Method � Pumped ❑Free Fall ❑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. 1 Ml UM 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7.697 S it SIGNED TITLE I r.,,[�J_ DATE ��`a -OJ L IIAI LC I.r N E A H JTHR E R -ME NTIMA LAI DEPARTMENT USE O rL Application Accepted By -- Date .�� Area Employee ID40 Grout Inspection By Date ❑ SP CIAL Well Permit , Pump Inspection By Date ❑ WAIVER Received Destruction Inspection // y Date Constructed Well Depth ft COMMENTS l(Y'f- �' a�r�,l JI r5 F/1��t �} - U 3 4,3S -- PE SC Received Chec Amount Date Permit/ Invoice# WellID# ` Codes Info B Cash Remitted Service Request# 7� s� P-0o EHD 43-02-006 _ MASTER WATER WELL PERMIT 12/6/2002