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WELL / PUMP PERMTT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA T HENT 304E WEBERA FL-STOCKTON CA 95202 - <br /> NON-REFUNDABLE <br /> �PERMIT /) _yJ r L(209)953-7697 FOR INSP/EICTIONS L{�,rREES/ 1 YEAR FROM DATE <br /> JOB ADDRESS �S^Za 'I .'�,/Yi Yf� < f /'f�G ��/J�� Y/ZIP Z-k- - <br /> CROSS STREETAPN 3PARCEL O 3 � ' \ <br /> / U U SIZE T <br /> OWNER NAME e/ �YYI'T-LI-�yy�t/Lr �� PHONE <br /> OWNERADDRESS CITY/STATE/ZIP <br /> CONTRACTOR 1�Lf}�ijj�/+�/ &12-7— ('PHONE <br /> CONTRACTOR ADDRESS 40 IY^ !�'YOL"�tL CITY/STATE/ZIP 7rl�^j 9 <br /> iUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT+ Z J YISTACT-E-//-ZIP <br /> 11 <br /> LICENSE fi(C-57 C-61 ❑D-09 ❑Other NUMBER 7 ` EXPIRATION DATE <br /> 3EOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range__ Section <br /> NTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> IfdiRerenr from owner. Water System Name antact ame or one um er <br /> vee OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> 11 Monitoring Wells number of wells numberofborings �/ numberofborin• <br /> B O 13 Soil Boring(s) Geotechnical ss <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Re air ❑Cross-Connection Repair <br /> VELL CONSTRUCTION <br /> Trilling Method ❑Mud Rotary ❑Air Rotary �Au er ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth r 7 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-10gal water) ❑Sand Cement .ruck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> rout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> EDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length_it Thick in ❑Christy Box ❑Stove Pipe <br /> -'NIP ❑Submersible ❑Turbine ❑Other HP Pump Set it Standing Water Level ft <br /> ELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated Bom ft to ft <br /> Sealing Material Neat Cement(94 Ib bag/5-10gal water) ❑Sand Cement sack mix/7 gal water p0--eentortne-FeRess- <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File OS pecs u mute, <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> )AQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> 1RRENT AND ACTIVE gWITHTCALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> )RKERSCOM ENSATIMI CE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)9 3-769 <br /> IED a TITLE trirw tlr/Ili/Lr7il�— DATE 11 zd D <br /> DEPA <br /> 1ppliwtion Accepted By Date ZU '� Area Employee ID#cq L � 3 G <br /> Grout Inspection By Date /f ZL( ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Reeelved <br /> uction Inspection By lDate Constructed Well Depth ft <br /> .NTS <br /> SC Received Check#/ Amount Date Permit/ Invoice# Well Info B Remitted ervice Request# <br /> I �'� ►� a 3 / 9 <br /> MASTER WATER WELL PERMIT <br />