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ELL / PUMP PERMIT -� ,AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D. . MENT 304 E WEBER. °FL-STOCKTON CA 95202 - (209)465-3420 NON-REFUNDABLE PERMIT r� CALL 209 953-7697 FOR INSPECTIONS �y^E�XXPIIR'E`S I t 1YEA/R�t'FRt,O,sMA DATE ISSUED JOB ADDRESS S-00 J, 6R-L'A0 '-b CITY/ZIP`) ?=—EQ �H \ ,TCI"\ y O CROSS STREET �1 N'F_IA7'eS' p ^ pPN PARCEL SIZE p OWNERNAME S.d��3J "720tn.i Coi�1PRoles � ot'. � PHONE OWNER ADDRESS CITY/STATE/ZIP OF-L,3 ( O� CONTRACTOR Io( . — PHONE _ 0I( ql -qI 3(JJ� � CONTRACTOR ADDRESS AA, A-R?.) iJLy r->. CITY/STATE/ZIP3AI! `AM&0Tj, / M �() y 9'20.1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-$7 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferemfrom Owner. eter ystem eme onract eme or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/h9odification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwelk 0Soil i f b b Boring(s) numberofbonayrs number of❑Geotechnical 0 'Well Destruction O Out-Of-Service Well ❑Out-Of-Service Well Renewal •�• ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION N, Drilling Method gMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 1q0t' ft Excavation_ glow in diameter �,Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter --(V-in Thickness/Gauge/ASTM Sched 13%wA,r )Ef Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth -Clh ft ❑Neat Cement(94 Ib bag/S-10 gal water) ❑Sand Cement .'ack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method %Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ` ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It WELL DESTRUCTION Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter(_in Total Depth t 0iD ft Depth to Water ft ❑Casing to be Perforated from Io ft to 1(00 ft Sealing Material .,Neat Cement(94 lb bag/5-10gal water) P(S :F"� sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method Pumped ❑Free Fall ❑Other 0-complete with Mushroom Cap-3�- _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 CONTRACTORSSTATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 244IOUIR ADVANCE NOTICE REQUIRED FOUR IINSPE TIONS-PLEASE CALL(2 53-7 7 SIGNED M TITLE (//LE �LESS D E CS� 0 A IL WA O N plow ME -f[!TIEA LT p PARTMENT U O ILY /� Application Accepted By Date � Area Employee ID# Grout Inspection By Date ❑ SP CIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspec i n By ` Date i z zii? Constructed Well Depth /ffft COMMENTS S ✓ 'n ' va W lt5 iA ?Y N 1 PE SC I Received I Check# Amount Permit/ Invoice# a e1116#ef Codes Info ash Remitted ate Service Request# J e7o el-; �� Un -P6 Co U Yi le UiS EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002