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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3N"FL-STOCKTON CA 95202 - (249)468-3420 <br /> s <br /> NON-REFUNDABLE PERMIT CALL 249 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> t g�4 I'3� �r� <br /> JOB ADDRESS L` .i C47YIZIP UO <br /> CROSS STREET ZZ � 4C APN r ��t_v�)� PARCEL SIZE __ <br /> OWNER NAME FFIIO <br /> �) �' � / � }N�E <br /> OWNER ADDRESS G/ / C[TY1S'rA7'E1ZIP ZA-1,4 <br /> CONTRACTOR Y/rC-L PHONE <br /> CONTILACTORADDRESS l7Yk�[ L / (I � CITYISTATEJZIP <br /> SUBCONTRACTOR Pt10NE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> y <br /> GEOGRAPHICAL INFORMATION. Coordinates X Y Township Z5 Rangelosi—cf Section <br /> INTENDED USE ❑DomestiOprivale ❑Irrigation/Agricultural ❑Industrial ❑Waler Quality Monitoring )Wsoil Sampling/Characterization <br /> ❑Public Water System <br /> If difTerenr from Owner: Waler SySLem Name Contaci Nameor Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well . ❑Well Alteration/Modification ❑Test Hole Other <br /> ❑Monitoring Well(s)_ numberofwells Moil Boring(s) —1;2-- number ofburings ❑Geotechnical urnberofborings <br /> Ll Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Cl Mud Rotary ❑Air Rotary 0 Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 111 <br /> Well Casing Diameter in Thickness/GaugeIASTM Sched ❑Steel 13 Mastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neal Cem,-nt(94 lb hug/5-10 gal wider) ❑Sand Cement suck unix/7 gal water <br /> ❑Bentonite(200/a solids) ❑Manuracturer Spec%solids % Name T ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP— Pump Set ft Standing Water Level tt <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth 11 D,Wpih to Waver ii ❑Casing to be Perrorated from ft to fl <br /> Sealing Material "t Cement(94 lb hag 15-10 gal waler) 11 Send Cement suck mix 17 gal water 13Bentonite Pellets <br /> ❑Bentonite(20°/a solids) ❑Manu racturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped )"'aree Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Suri'ace Pad <br /> 1 HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 ADVANCE NOTICE REQUIRED FQR INSPECTIONS <br /> SIGNED TITLE �Y� DATE <br /> 4 <br /> 44 <br /> LP <br /> r <br /> n,N„° a <br /> HE 1TH;E <br /> F;' <br /> 7r <br /> DEPARTMENT USE ON <br /> Application Accepted By { Date ONLY 3 Area Employee ID# <br /> Grout Inspection By Date�� a� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS_ <br /> PE SC Amount Check#1 Receive Date nvoice# Well►D# <br /> Codes Info Remitted Cash (� ) !Service R ueslJ# <br /> C+'I r L <br /> ti <br /> EHD 43-02.006 MASTER WATER WELL PERMIT <br /> 5/712002 ((( J <br /> 1 <br />