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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONME EALTH DEPARTMENT 304 E WE] :3""FL-STOCKTON CA 95202 -(209)465-3420 NON-REPUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS —API RES 1 YEAR FROM DATE ISSUED LA / JOB ADDRESS 16 1• n Z� r� (),' vCITY/-LIP �f L, •Z.. m s CROSS STREET ,t APN PARCELSIZE OWNER NAME YHONE I��JC/ �2 .7—19dLY 51 OWNERADDRESS CITY/STATE/ZIP CONTRACTOR %sS��- PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SURCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZI P LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Pr{vate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Q ❑Public Water SJJv.stem Ifdifferent from U.vner: O r rilem en% Coiloici Nimw or.IOnC Ynl r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑O:her ❑Monitoring Well(s)_ numberof—I s ❑Soil Boring(s) numb—I'toriags ❑Geotechnical numberofborings ❑Well Destruction *Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other J Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth _Il Well Casing Diameter_in Thickness/GaugelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel El Other Grout Seal Depth fl ❑Neat Cement(941h bugl S-10gu/water) ❑Sand Cement sock Inix/7 gat water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Relaidant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width__ ft Length fi chick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Sel fi Standing Water Level it WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth It rrpth to Wate: R ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag,15-10 gal water) ❑Sand Cement .ruck 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. 1 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. MINI 24. OU ANCE NOTICE REQUIRED FOR INSPECTIONS Z SIGNED - TITLE =-��.�-r DATE in 4 / 1 p OU. F Pk)2jC j r rH N1,iN V I I , EN'IR I j El EPARTMENT USE Y Application Accepted By ate Q AreatAIVER Employee IDN Grout Inspection By _ Dale Well Permit qj Pump Inspection By Date Received,._--., I Destruction lnsp�ionBy Date Constructe4 Well Depth </r'z.(:%•ra. . -.ft COMMENTS PE SC Amount / Received Permit/ Codes Info Remitted Cash By Date tN Invoice _�Yell_ID$ o- oD VrDu [ 5 37 06, -006' EHD43-02 �:.��:G�'Gf.:� ...:- _fi <!.Z%. .c.,o; ,G' �-v r�-sx..� aal- MA57ERWADER WELL PERMIT