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WELL J PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHVPPARTMENT 304 E WEBE AVE 3a" FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT c CALL /•(209) 9/53�-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ✓ ./ J / ! Vy rh 2e U/ l CITY/ZIP_ / G ( 5 - CROSS STREET I �//" �/ �,/� ��/AAPJNf 20/— 06QO - � PARCELSIZE _//, OWNER NAME /'V • / 1 (i 1G�J � "/v / r/ /�/ 1 PHONE `�('� Tho 10— — /rla'f OWNER ADDRI CONTRACTOR CONTRACTOR 977,*) I AWmNE _HOZ& CITY/STATE/ZIP SUBCONTRACTORs 'y -/� , /A LG V i AVE PHONE SUBCONTRACTOR ADDRESS l�VCT C aVIIII Z 'rCITY/STATE/ZIP 1 LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION 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 ontact Name or Phone Number TYPE OF WORK XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole ❑ Other Z.494OF-11t C7/(S 1Q� ❑ 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 rl New Pumn ❑ Pumn Renlacement ❑ Pumn Renair ❑ Cross -Connection Renair WELL CONSTRUCTION Drilling Method ❑ Mud Rotary )4ir Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depthlo % ZV ft Excavation m diamet ❑ Open Bottom ❑ Gravel Pack / Gravel Siz ls in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched Liv 1,qrSteel APlastict?0 ❑ Stainless Steel ❑ Other Grout Seal Depth K#" /V5 ft ❑ Neat Cement (94 lb hag / 5-10 gal water) 46 ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Grout Placement Method ❑ Pumped I1(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 ft 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 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI 24 HOUR A CE NOTICE REQUIRED FOR INSPECTIONS— PLEASE CALL (209%))333 9 -7697 M SIGNED <D^C'CA TITLE?S��i�u,2 DATE `� '•' 2-W"74 (� EPARTMENT USE25LY Application Accepted By�j Date — I Area Employee ID# Grout Inspection By Date ❑ SPE IAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Codes Info Received Check#/ By Amount Remitted Date Permit/ Servic a nest # Invoice # Well ID# EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002