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j&VELL / PLUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE AWENT 304 E WEBER FL - STOCKTON CA 95202 - (209) 468-3420 AgJA-1KEFUNDABLE PERMIT CAUL, LU99:0-/OV / FOR INSPECTIONS hArlitLJ 1 YEAR FROM JJATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET APN PARCEL SIZE LAND USE APPLICATION # OWNER NAME PHONE OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other CITY/STATE/ZIP PHONE CITY/STATE/ZIP PHONE CITY/STATE/ZIP, NUMBER 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 ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal n New Pmmn rl Pumn Renlnrement rl Pmmn Rennir 17 (ince-t`nnnertinn Rennir WELL CONSTRUCTION SC Info 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 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 It 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. 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. MINIVIUM 24 HOUR ADVANCE NOTICE REQITIRED FOR INSPECTIONS SIGNED TITLE DATE Application Accepted By, Grout Inspection By Pump Inspection By Destruction Inspection By COMMENTS DEPARTMENT USE ONLY Date Date Date Date Area Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft 11r C d PE Codes SC Info Received B Check#/ Cash Amount Remitted Date Permit/ Service Re uest # Invoice # Well ID# EHD 43-02-006 MASTER WATER WELL PERMIT 12/22/2003