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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECI IONS EXPIRES i YEAR FROM D TE ISSUED � y q � CITY/ZIP IJOB ADDRESS 7 CROSS STREET !J �A- 0*20't I'06 —I I PARCEL SIZE-%,K LAND USE APPLICATION# A OWNER NAME L n I} IL-'j ` IUft21 L-Y A) -1—U!>172 PHONE OWNER ADDRESS `2�Z 49 17. Lr!r-�A4>r�IZS� I-V CFTY/STATFJZIP 7ma CONTRACTOR �r/!Tlr7a'G-. [PHONE " h57� /7 2-7 CONTRACTOR ADDRESS 77�C! j6!f"C12- L/}NL CITY/STATFJZIP7��Lf TD7lJ� 1T1I 95-` SUBCONTRACTOR V 4 w 119014-1-14,16-7 PHONE '-'X77 f - SUBCONTRACTOR ADDRESS I✓!/ /�rY'rH S/F.- CITY/STATE/ZIP )5LETp.y, � 4S by/ LICENSE C-57 D C-61 D D-09 D Other NUMBER qW'/O-/ EXPIRATION DATE d r7b GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ �t INTENDED USE ❑Domestic/Private D Irrigation/Agricultural ❑Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization D Public Water Syystem If di(ferenlfiom Owner: Witter Sym.Namc Conuiet Name or Phone Number TYPE OF WORK D New Well ❑Replacement Well D Well Alteration/Modification ❑Test Hole D Other ❑Monitoring Well(s)_W of wells D Soil Boring(s) x°fb°nngi XGcotechnical�s0f bonngs DWell Destruction D Out-0f-Service Well ❑Out-0f-Service f-Serve Well Renewal D New Pump D Pump Replacement D Plump Repair D Cross-Connection Repair WELL CONSTRUCTION Drilling Method D Mud Rotary D Air Rotary XAuger D Cable Tool ❑Push Point ❑Other Proposed Well Depth 7-0 ft Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter D Conductor Casing in diameter / Conductor Casing Depth ft \ Well Casing Diameter in ThicknesVGauge/ASTM Sched D Steel ❑Plastic ❑Stainless Steel D Other Grout Seal Depth 2fO ft )dNcal Cement(94 lb bag/S-/0 ga/water) D Sand Cement sack mix/7 gal water D Bentonite(20%solids) D Manufacturer Spec%solids_% Name D Specs on File D Specs Submitted Grout Placement Method ❑Pumped D Free Fall ,Kath,, -CL D Retardant/Accelerator(name) PEDESTAL Installed By D Driller D Pump Contractor D Other D Concrete Pedestal Dimensions: Width ft Length ft Thick in D Christy Box D Stove Pipe PUMP D Submersible D Turbine D Other HP Pump Set R Standing Water Level ft WELL DESTRUCTION ❑Open Bottom D Gravel Pack ❑Uncased D Other Well Diameter in Total Depth ft Depth to Water ft D Casing to be Perforated from It to ft Sealing Material ❑Neat Cement(94th bag/5-10ga!water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets D Bentonite(20%solids) D Manufacturer Spec%solids % Name D Specs on File ❑Specs Submitted Placement Method D Pumped D Free Fall D Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 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. 1 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. NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE 5ll FF /VI�T�� DATE ROAD L— LINJ. GRANT it It �Ii �. Y i . i 0 211\ O 21` 22 - - - - - DEPARTMENT USE ONLY EmployeHEALTH � E Application Accepted By Date��f—Gc Area EmPloyeeID# ) � Grout Inspection By Date,&�—/0' 'S ❑ SPECIAL Well Permit qlaq Pump Inspection By __VVy Date ❑ WAIVER Received / Destruction Inspection By Date Constructed Well Depth It COMMENTS PE SC Received Check#/ AmountDa1t Permit/ lavofce# Well IDN Codes Info B Remitted Service R uest# s.Tz DOM3 3M 1`13IE7S Hy57 EHD 43-01-006 MASTER WATER WELL PERMIT 1122/2003