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WELL / PUMP PERMI SAN JOAQUIN COUNTY ENVIRONMENTAL TH DEPARTMENT 30 EBER AVE 3"a FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT '- "/ "7 a Area Employee ID# ✓ ! / J CALL (20919.5,3-7697 FOR INSPECTIONS EXrIXLN IYEAR FROM DATE "'% D ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched CITY/ZIP?J Ifs Y' JOB ADDRESS�77Z 15 V .51-FeAl CROSS STREET kt�APN ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor PARCEL SIZE �� PWA ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible ❑ Turbine ❑ Other HP OWNER NAME ❑ Other ft ❑ Casing to be Perforated from ft to ft Sealing Material ' ❑ Neat Cement (94 lb bag / 5-10 gal water) V$and Cement PHONE OWNER ADDRESS Name ❑ Specs on File ❑ Specs Submitted Placement Method Pumped ❑ Free FaUV— ❑ Other CITY/STATE/ZIP 97ykj �' CONTRACTOR �1 ❑ Complete to Existing Surface Pad PHONE � CONTRACTOR ADDRESS C, / CITY/STATE/ZIP J TYA—/qS,—5 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS A CITY/STATE/ZIP LICENSE -57 -61 O D-09er 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 Sstem 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) number of wells ❑ Soil Boring(s) number of borings ❑ Geotechnical number of borings Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal r -r wt_... n - rn D....,.. De..l.,,.e». -..♦ rl D..-- V -;o n rrnec_rnnnnrtinn R-ir WELL CONSTRUCTION '- "/ "7 a Area Employee ID# ✓ ! / J 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 DESTRUCTIONX—'inttom ❑ Gravel Pick ❑ Uncased Well DiameteTotal Depth � ft De th to Water ❑ Other ft ❑ Casing to be Perforated from ft to ft Sealing Material ' ❑ Neat Cement (94 lb bag / 5-10 gal water) V$and Cement sack mix / 7 gal water 13 Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method Pumped ❑ Free FaUV— ❑ Other Complete with Mushroom Cap -- , 5—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. M1 U 24 O R V OTI E REQUIRED FO 1 ECTIONS —PLEASE CALL (209) 9- i SIGNED TITLE DATE 1 Application Accepted By`:�- 7,30 •Grout Inspection By _ 34�4ump Inspection n Destruction I o COMMENT DEPARTMEN9' U,6 ONLY- Date .h? 3 '- "/ "7 a Area Employee ID# ✓ ! / J Date. ❑ SPECIAL Well Permit Date ❑ WAIVER Received �- Date/�!�3 Constructed Well epth It K T PE SC' Received Codes Info B heck# s Xmount Permit/ # Remitted D to Service Request # Invoice ID# 402 � 5 p I EHD43-02-006 . �. ..,...... 12/6/2002