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WELL / PUMP PERMIT SAN ,JOAQUIN COUNTY EMIR ; ,AL HEALTH DIWTMENT r 304 E WEBER *R11 FL - STOCKTON CA 95202 - (209) 468-3420 NON- A f n� CALL 209 953-7697 FOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED [_ -JOB ADDRESS -I— I I CITY/ZIP � � 6A Q606 CROSS STREET) A'" OWNER NF \v6 OWNER ADDRESr' CONTRACTOR CONTRACTOR ADE SUBCONTRACTOR APN if PARCEL SIZE PHONE � 007,145A_ "0/145A CITY/STATE/ZIP 5-kr1_ V( A - q PHONE -Aq-I -LI PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 OOther ( ',1LI/ /,) /1 NUMBER W UlV I W EXPIRATION 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 gWther C;[% J V ZST JIJKU f.v-.-.> ❑ Monitoring Well(s) number of wells ❑ Soil Boring(s) number of borings ❑ Geotechnical numbe of borings ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal rl New Piimn I-1 Piimn Renlarement fl Piimn Renair n Crncc-Cnnnectinn Renair WELL CONSTRUCTION InI Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point %Other � � yo( , �� L l0 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 lb bag/ 5-10 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 ftSealing Material ❑ Neat Cement (94 lb bag / 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 COMPEN TION LAWS. MINIMU HO R A ANCE N TICE REQUIRED FOR 1 SPECTJO S —.PLEASE CALL (209) 9 3-76?7 SIGNED TITLE / ry �� DATE I O ��//II DEPARTMENT USE ONLY Application Accepted By \Fb Ali. � A� Date I -a o'� J J� Grout Inspection By Date Pump Inspection By Date Destruction Inspection By Date COMMENTS Area Employee]D# p ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Codes SC Info Received Check# Amount Date Permit/Invoice B Cash Remitted Service Request # # Well ID# 3� 3$ 33 Z du l u 5 X200 u ! t75 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002 �/�' V o o 313 T ra a v v H