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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'e FL-STOCKTON CA 95202 -(ZUY)4011-341.1) NON-REFUNDABLE IPERMIT 7 `) CALL 209 X9)53-76/977 FOR INSPECTIONS EXPIRES I YoEAR FROM DATE ISSUED JOB ADDRESS / / / ✓ (-31.---v CITY/ZIP `' /GZ/I /` 'C > �Dlv-X00-/y0. CROSS STREET � ra� APN PARCEL SIZE p OWNER NAME P AJAZ A� Q/I� L� ,r -/ 'PHONE .[/ OWNER ADDRESS I Y 9 7 2 /'7 u S/ 7 N �Cl CITY/STATE/ZIP /r 'E�'1`e«C '2 i"f -51 3 3 ` PHONE : I/'-J 7 s CONTRACTOR �4 S 7 `Y�/)G/��✓ �� 9 ��1) `'/ CONTRACTOR ADDRESS .L Iy7 K/ /-7�n' c TT CITY/STATE/ZIP l/'r /J'�✓ p, SUBCONTRACTOR PHONE l SUBCONTRACTOR ADDRESS �7 CIT'/STATE/ZIP LICENSE ❑C-570 C-61 ❑D-09 ❑Other C NUMBER Z EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section (A INTENDED USE P,Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Sail Sampling/Characterization \],1 [3 Public Water System on=t Name or ane Number \ Irdffferem from O..-net. aier ysrem ame ` TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification O Test Hole ❑Other number otborin• \j numberorweua p Soil Boring(s)s namberorbodnip ❑Geotechnical ❑Monitoring Wells) g() ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump 0 Pump Replacement ❑Pump Repair ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hug/5-10 gal wuter) ❑Sand Cement .ruck mix/7 gal water ❑Bentonite(20e/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fali ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ft Lengthft Thick in ❑Christy Box ❑Stove Pipe PUMP 54ubmersible ❑Turbine ❑Other HP j _ Pump Set JVD ft Standing Water Level WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Pertorated tom ft to ft Sealing Material ❑Neat Cement(94 th h g/5-10 gul water) ❑Sand Cement suck mor 17 gal water ❑Bentonite Pellets ❑Bentonite(200/6 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 1 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 W . UNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED/7- TITLE D "&' DATE i O IN O pul.(IC A N'I DEPARTMENT USE NLY Application Accepted B Date 0.2-.27-03Area �/r Employee ID# -- Grout Inspection B Date ❑ SPECIAL Well Permit Pump Inspection By fr Date 9 e ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COMMENTS PermitPE SC Amount Chec Received Date cc Req Invoice q Well 1Dp Codes Info Remitted Cash B Service Request N 80032880 EHD 43-02-006 MASTER WATER WELL PERMIT 5nn-)002