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ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D. NT 304 E WEBER. 0L-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y JOB ADDRESS qSa I �. AAf--x,14 o1 2D, CITY/ZIP Y CROSS STREET _I 1i't t-t'ELI.l7 APN PARCEL SIZE OWNERNAME -71.--1no-n b- ---0LA'f C-,b Ir-'e' KS . PHONE (Jn OWNERADDRESS I+-T� PI�1'�r,t\— PoPEE'. CITY/STATUZIP�� l( '/I� "P, CONTRACTOR )V,�II'EQ— L�e.t_L_ i�L ©L,^(-J1�11N(�, ^PHONE �� � 1� -1\(JOA ID'q CONTRACTOR ADDRESS �("�� I�� !-JI.-VJ7l CITY/STATE/ZIP f)µL`�h,G,,,jTT` A95QQf qI s SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITWSTATE/ZIP LICENSE C-57 ❑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 If different from O,srer Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other numberofwells numberofborinyrc number of borings ❑Monitoring Well(s) ❑Soil Borings) 11 Geotechnical g[Well Destruction ❑Out-Of--Service Well ❑Out-Of--Service Well Renewal ,`^\ 13 New Pum 13 Pump Replacement ❑Pum Repair ❑Cross-Connection Repair O' WELL CONSTRUCTION Drilling Method )!�-Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 1 '3-\ ft Excavation in diameter XOpen Bottom ❑Gravel Pack/Gravel Size in diameter V) ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Scheni.V LL Steel- ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-l0gal water) ❑Sand Cement ,tack 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) if PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length_fl Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level it WELL DESTRUCTION AOpen Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_;in Total Depth I,-'H ft Depth to Water ft )1 Casing to be Perforated from 11) ft to 1ql--- ft Sealing Material Neat Cement(94 lb bag 15-10gal water) � sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec a%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method IK Pumped ❑Free Fall ❑Other Complete with Mushroom Cap�R 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI UM 24 OUR VANC NOTICE REQUIRED FOR SPE(,TIONS—PLEASE CALL(20Z 3- SIGNED TITLE /LE //[;L_ S DAT J Z ti IN 11 A NT- nt IMENT L ii 70 EPART ❑MSE Date 9 Application Accepted By - � Date /-[kY-.z Ld�u'z� Area 1 Employee lDH�y Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By / Date ` ❑ WAIVER Received Destruction In�speecti By ` Date 1 2 Its Constructed Well Depth It COMMENTS W PE SC Received cc Amount ate Per It/ Invoice# Well ID# Codes Info B ash Remitted Service Request# 00 Q EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002