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WELL / PUMP PERM' SAN JOAQUIN COUNTY ENVIRONMENTA, ALTH DEPARTMENT 31WVEBER AVE 3aa FL- STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IIISSSUED/may �J ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter 5 � Well Casing Diameter in Thickness/Gauge/ASTM Sched CITY/ZIP JOB ADDRESS '"' �.�d ` ► ® Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other CROSS STREET PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other APN Q5 PARCEL SIZE OWNER NAME3� PUMP ❑ Submersible ❑ Turbine ❑ Other HP PHONE 11-4-6 W(, /° ,1.. t ( v CITY/STATE/ZIP ✓ n OWNER ADDRESS ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Complete with Mushroom Cap ft below grade ` PHONE CONTRACTOR & CCVe CONTRACTOR ADDRESS CITY%/STATE/ZIP e' r ' PHONE � SUBCONTRACTOR SUBCONTRACTOR ADDRESS VLr-r'"1 V l 1 1 CITY/STATE/ZIP V 1 p LICENSEID— ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER, EXPIRATION DATE ,_.___..._. ... v TownshiD Range _ Section (i1K0#j KAYHH.ALIry1.vRMA1,vi9: -.0i i.—Ca i - - 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 one Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification u lest Hole u vtner number of wells number of borings number of borings E3 Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical ❑ Well Destruction ❑ Out -Of -Service Well 1 ❑ Out -Of -Service Well Renewal ❑ New Pump ❑ Pump Replacement ❑ Pump Repair 0 Cross -Connection Kepair WELL CONSTRUCTION Drilling Method ❑ Mud Rotary °lir Rotary ❑ Auger'' ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft xcavation &AO in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel PRIastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 lb hug / 5-10 gal water) ❑ Sand Cement .tack mix/ 7 gal water Bentonite (20% solids) ❑ Manufacturer Spec % solids % 71< 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 It Standing Water Level ti WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other It ❑ Casing to be Perforated fro n It to ft Well Diameter in Total Depth ft Depth to Water 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 THATTHE WORK WILL Isc uvtvr, uv Aa 4vlcUHl.. Vv' 1" or+:. 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. 24 HOUR ADVANCE NOTICE REQUIRED FOR 1 ur:ra Application Accepted By 'tt2z Grout Inspection By �( Pump Inspection Inspection By Destruction Inspection By COMMENTS Date ONS f'� DATE 13 G..a Area Employee ID# -7 3 SIC) ❑ SPECIAL Well Permit ❑ WAIVER Received Date Constructed Well Depth 0 ft PE Codes SC Info Amount Remitted Chec ash Received By Date Permit/ Service Request # Invoice # Well ID# / EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002 9