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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMLNT 104 E.WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-1420 NON-REFUNDABLE PERMIT CA1,1,(2M 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED to JOB Ar1DRESS CI'I'YIZ1P — > 0 CRASS STREET APN X5.3 .330 '.3 L-PARcEI.SIZE LAND USF.APPUCcrATfON 4 1 OWNER NAA:F. 1Y1/�f � �x YZ• PHONE OWNER ADDREFS / /! ^ CITY/STATF/ZIP 41 CONTRACTOR ZPS V ,g / �t. 4 nL(� Jetfi I � (�J PIiUNI CONTRACTOR ADDRESS!/t W j ^r7 e/i �*-� i a� V /wv s Cn V/SI'A'rEIZH- Aegw SUBCONTkAC;I'OR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �LlcEnsE 0C-57 O C-6I ❑D-0V the, 0 _©Z NUMBER 7 3 T f7�7 EXPIRATIONDAiE ' 30 0 GFOGRAPHICAI.INFORMATION: Coordinates X Y__ Townshlp Range Section INTENDED USE ❑Domestic/Private ❑IrrigauontAgrieultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization ❑Public Water System lfdtff'nmt l'rum Own r: -- ager System Name Contna Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well O Well Alteration/Modification ❑Test I lole ❑Other 0Monitoring Well(s) _W of wells 0Soil Buringfsl _ 4ofbnnngs ❑Geotechnical antborings O Well Destruction O Out-Of-Service Well O Out-Of-Service Well Renewal ❑New Pump S36&ttmp RepLcement ❑Pump Repair ❑Cross-Conrection Repair WELL CONSTRUCTION Drilling Method O Mud Rotary ❑Air Rotary O Auger 0(:able Tool ❑Push Point ❑Other-- Proposed Well Depth fl Excavation in diameter ❑Open Bottom ❑Gravel Pack,'Gravel Size in diameter ❑Conductor(rasing , in diameter ; Conductor Casing Depth fl Well Casing Diameter - In Thickness/GaugelAS1 NI Sched ❑Steel O Plastic O Stainless Steel ❑Other Grout Seal DepUl _A O Neat Cement(94!h baK/S-10gal water) ❑Sand Cernent_ _ cock tx t/7 gal water n O Dentonite(20%solids) ❑ Manufacturer Spec%solids % Namc _ O Spas on File ❑Spas Submitted Grout Placement Method O Pumped ❑Free Fall O Other ❑Retardant/Accelerator(name) PEDESTAL. Installed By ❑Driller ❑Pump Cortractor ❑Other ❑Concrete Pedestal Dimensions: Width R length ]i Thick _ in ❑Christy Box 0 Stove Pipe FUMY ubmersibic ❑Turbine ❑Other HP_ � Pump Set_. — It Standing Water Level it r WELL DE51'RUCTION ❑Open Bottom O Gravel Pack 7 Uncased O Other Well Diameter in Total Depth ft Depth to Wa(cr R ❑Casing to be Perforated from -_—ft to ft Sealing Material ❑Neat Cement(94 lb hag/.f-l0 gal mater) D Sand 0:mens - . sack mix!7 gal water ❑Hentomte Pellets ❑Hentnnite(20%solidsl ❑Manufacturer Spec 4;solids__ % Name — _ _ ❑Specs on Pile O Specs Submitted I Placernent Method ❑Pumped O Free Fall ❑Other_. O Complete with Mushroom Cap ft below grarie ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK INILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGUILA-riONS. 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 COMPE . MINIIL1UM 24 HOER ADVA.NCF. NOTICE RE U[RED FOR INSPECTIONS Q SIGNED TITLE, `CC DATE 9-- / –0 y 7 A DEPARTMENT USE ONLY Application Accepted By / Date Area_�-I ER:Aloyee ID# �c ZI (irtwt Inspection Cy_ . T Date ❑ SPECIAL Well PC,-Mit Pump Inspatiox By_ Date ❑ WAIVER Received Destruction Inspection By Date — Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amounh Dw ermill Invoice# Well IN Codes Info By Remitted" Service Request# �.f-3 t�-1 v S�• �3 �o K c�• t 0 S L�, - o -�� F:HD a]•DI-D06 MASTER WATER WELL PERMIT 1272'IOD7