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WELL/ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 - (209)468.3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIO\:ti EXPIRES 1 YEAR FROM D.4TF ISSUED (GI� to (A Q1j71'S i JOB ADDRESS _ Crr\'/ZIP � �� /�/� i L� L/�J•� 0 CROSS STREET vA APN OVyflr VC.(J �1 PARCEL SIZE J m h OWNERNAME _ PHONF. - rJ�1 S OWNER ADDRESS CITY/STATE/ZIP �/1•/.�`,/,y/(/,{]�-�y� 1117 � C� CONTRACTOR PHONE C+C/�"lj�1,✓LQ-✓�JG)��/�_�_ v CONTHAC"TORADDRESS a- - CrrY/STATEIZIP V`�(�{(�"�,/ /J�•-s SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ITV ATF./"LIP LICENSE ❑C-57 C-61 ❑D-09 ❑Other NUMB EXPIRATION DATE GEOGRAPHICAL INFOR ATION: CoordinateS X Y Township Range Section fi 1NTErvoeo USEomestic/Pmate 11Irrigation/Agricultural 13Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactenration ^y ❑Public Water Setem _ Ird,fTemnt from weer. onozNa—or PhoWT.46F, TYPE OF WORK ❑New Well 13 Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) _ nambwofwc11s ❑Soil Bori ng(s) —berafbod.p ❑Geotechnical numberofborings ❑Weil Destructio ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump Pump Re lacemem ❑Pump Repair O Cross-Connection Repair WELL CONSTRUCTION' Drilling Method CI Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other fProposed 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 ThickncWGauge/ASTM Schell ❑Steel ❑Plastic 0 Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement{94 1h bag/S-!0 gal wafer) ❑Sand Cement .vack mix!7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 13 Driller O Pump Contractor ❑Other _ Concrete Pedestal Dimensions: Width ft Length ft Thick_ in ❑Christy Box ❑Stove Pipe PUMP Suhmersible ❑Turbine ❑Other HPJYP..pSe1-,ff,,ffjft StandmgWaterl.evel D11 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 ti Scaling Material 0 Neat Cement e94]b hag/5-10 gal waler) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets Cl Bentonite(20%solids) ❑Manufacturer Spec%solids"% Name _ ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other D Complete with Mushroom Cap R 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, IM[UM 24 R A VANCE NOTICE REQUIRED F R INSP CTIONS-PLEASE CALL,(209)953-7697 SIGNED TITLE DATE t PAY s H A HI)EFajjT&4EVr 1 71 J 'TL ��j,(�DEPARTMENT USE ONLY Application Accepted By`LYt/Y+ti040`l.[ `{ i t,wVA[` 4 Date --)- Area c�Zj. � Employee ID# _ Grout Inspection By Date— ❑ SPECIAL Well Permit Pump Inspection B te ❑ WAIVER Received Destruction Inspection By Date T Constructed Well Depth B COMMENTS PE SC Received Check#/ Amount Date Permitl Invoice# Well IDN Codes Info B as Remitted Request,, 3�1 50 1�9 7/JM i EHD 43-02-006 MASTER WATER WrLL PERMIT 1�/Fnnrn