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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IVTMENT 304 E WEBER al' FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (2009) 9553-7 � I 1 EXPIRES 11}Y�jE.�AR FROM DATE ISSUED CALL ��% JOB ADDRESS / 3 / Al. I/V l ` eV Zd1 Y CITY/ZIP CROSS STREET `Cl ✓ Z&B 2 4 2006 PARCEL SII)Z/E�/J OWNER NAME ,u j �7 / 3 /V PHONE �O] `7 %dj -/73 OWNER ADDRESS 4 N `G PERMIT�'WY/STATE/ZIP ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor //yf CONTRACTOR V 5 • PHONE CONTRACTOR ADDRESS -7 / /��/ CITY/STATE/ZIP , (� 0 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 Other li/ NUMBER �?d-3(0EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole Other d ❑ Monitoring Well(s) number of wells ❑ Soil Boring(s) number of borings ❑ Geotechnical number of tg&gs ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal rl New Pm— fl Pmmn Renlacement n Piimn Renair f-1 Crnss-Cnnnectinn Rennir WELL CONSTRUCTION Check#/ as Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 Ib hag 15-10 gal water) ❑ Sand Cement sack 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 ft WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Diameter in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to ft Sealing Material ❑ Neat Cement (94 lb bug / 5-10 gal water) ❑ Sand Cement 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 ❑ Complete with Mushroom Cap ft below grade ❑ Complete to Existing Surface Pad I 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. 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 COMPENSATION LAWS. �=' NCE NOTICE REQUIRED F4X= ION PLE SE CALL (209) 3--767 SIGNED TITLE . =� DATE :)- P Application Accepted By Grout Inspection By Pump Inspection By Destruction Inspection By COMMENTS DEPARTMENT U E ONL Date Date Date Date Employee ID# 59-t� ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE SC Received Codes Info B Check#/ as Amount Date Permit/ Invoice # Well ID# emitted Service Request # 8 s 3 �44z_ oto `� o.60 EHD 43-02-006 MAS -1 EK WA I EK WELL PEKMI 1 12/6/2002 F2