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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> `I <br /> JOBADDR$SS 1L\ "STLO � M CITY/ZIP 'Z11-INr C1Z �� \�PiN� I D <br /> CROSSSTREET DQ <br /> APN C7 ] PARCEL St2E 3:01/'H-2, F <br /> OWNER NAMEr\ F. <br /> �,3r+�t��n10��11 �Q.�l� PFIONa�_\ <br /> OWNERADDRESS T .� ��� ���� _ CITYISTATE/Z1PS���^ L VY I <br /> CONTRACTOR P}`II EEC�ZR <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP \V`-l�.►r��D�l �y�,\_�.�S.1LY <br /> SUBCONTRACTOR N-\),\" - PHONE <br /> 1 ,a <br /> SUBCONTRACTOR ADDRESS \y VA CITY/STATE/ZIP <br /> LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER d���` EXPIRATION DATE_�B 3o I Oto <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization r�{ <br /> ❑Public Water Sry5tcm - <br /> irdifferemfromOvmeewater System Nam Doter ame or arc,um r �,/� <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Wel l Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s)_ numtxr f—IIs ❑Soil Boring(s) numberurbori"br ❑Geotechnical n.mberorborinp <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Or-Service Well Renewal V+ <br /> 11 New Pump XPump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter_in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(94 1b bag/5-10gul wirer) ❑Sand Cement .tuck tmk/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller to Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length R Thick in ❑Christy Box Cl Stove Pipe <br /> PUMPSubmersible ❑Turbine ❑Other_ HP�Q Pump Set 11 R tl Standing Water Level_� �11 <br /> WELL DEs ttu FON ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water tl ❑Casing to be Perforated from it to 11 <br /> Sealing Material ❑Neat Cement(94 1b bug 15-10gu1 writer) ❑Sand Cement .ruck tnir/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(201%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped --"❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap H below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> rn` (�\\ MINIMUM 24 HOUR ADVANCE NOTI REQUIRED FOR INSPECTIONS <br /> SIGNS-ys Y'— �` ���SL TITL!szl� � DATE , <br /> T <br /> JL HA\YpvlD <br /> Lot I 604 <br /> S N OUNIY <br /> " jTAL <br /> MENT <br /> Ilk <br /> EPARTMENT USE <br /> Application Accepted By '--' Date Area Employee 1D# <br /> Grout Inspection By _ _ _ Date [ISPECIAL Well Permit <br /> Pump Inspection Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth R <br /> COMMENTS /moi r��D!lYyldLl� /1 �7r� 5 < /=tel c/ et�lra <br /> PE SC Amount Check# Received Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted ash By Service Request# <br /> ZM 190 z57) 172-3!a, rr a <br /> EHD 4342-006 MASTER WAFER WFLt.PERMIT <br /> 5n/2oo2 <br />