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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEVWTMENT e A� , 304 E WEBER "D FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT/ CALL(209)953.769 AOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 1 �J / �V e_ CITY/ZIP 7 �r CROSS STREET �t4J 9-- APN _ �� / / � -7' �� PARCEL SIZE OWNER NAME tY^W t'^ PHONE f� - +-7-6 OWNER ADDRESS 2(eCV 04-ydll P-o r"C CITY/STATE/ZIP all I rag �/�/�7y1 CONTRACTOR �Ll e-e- g1,n ��NZ' 4►1 PHONE 20 e wo f— (Z � �� )) f� 5 , � - CONTRACTOR ADDRESS /11.�L1 �LK)G%Z� (��/( , CITY/STATE/ZIP ' a tl SUBCONTRACTOR /�tit�'/}-LyY ✓�.1G /7 PHONE 5Z'0 '- LqL � 4ou SUBCONTRACTOR ADDRESS / /� ( '+GSIX��/J- 1� CITY/}STATE/ZIP (44N-1 {TZ I LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER S 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 Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ')&Other n ❑Monitoring Well(s) number of wells ❑Soil Boring(s) number of borings ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION 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 tt ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement .suck 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 tt 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 tt Sealing 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 I 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 WOR PENSATION LAWS. MINI UM 24 H P U A NOTICE REQUIRED FOR INSPECTIONS—/PLEASE CALL(209))953-769 SIGNED TITLE � i Yt DATE 1 i AN J01,0UP CUU TY In Or v v Hj)JVIIJON ' DEPARTMENT Ujf 9,NLY Application Accepted By Date ,- Area Employee ID# Pwar'Inspection By Date13SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date Permit/ Invoice# WellID# Codes B Cash Remitted Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002