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WELL/PUMP PERMIT <br /> SANOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT zo 5 O 1 304 E WEBER AVE 3`°FL-STOCKTON CA 95202 -(209)468-34ZO <br /> NON-REFUNDABLE PERMIT CALL(2 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 <br /> -7 �2-fQ-C m <br /> JOB ADDRESS Z3i4r �B-L(�✓7-Ar^) i�� �� CITYIZIP � <br /> / 0 <br /> yb APN Zc' i U�� Z } PnRCELSIZE /�, ;- <br /> CROSS STREET Cyt <br /> OWNER NAME C f r -�'r L— PHONE <br /> OWNERADDRESS i� '�Y� CITY/STATE/ZIP <br /> PHONE } <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR <br /> PHONE g H�- <br /> SUBCONTRACTOR ADDRESS Z3 �S = CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 4'f Z S Z— EXPIRATION DATE <br /> c <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township, Range Section <br /> INTENDED USE ❑Domestic/Private ❑I rrigation/Agricullurel ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System omm, armor rwe,om <br /> Itdiftermt from Own- -, ynem-- <br /> TYPE OF WORK 0 New Wet] ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of borm a <br /> numberofwells (((��� numberofbonnss ❑Geotechnical <br /> El Monitoring Well(s) Soil Boring(S) � � <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pum2 ❑Plump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool Push Point ❑Other <br /> Proposed�1- Depth A Excavation 44— diameter ❑Open Bottom ❑Gravel Pack/Gravel Sipe in diameter <br /> R <br /> ❑Conductor Casing in diameter / Conductor Casing Depth � <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement ,ruck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File Q Specs Submitted 3 <br /> Grout Placement Method ❑Pumped ❑Free Fal] ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed BY ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_Ii Length—ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine O Other HP Pump Set fl Standing Water Level It <br /> 4R%Wt DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter_in Total Depth It, Depth to Water fi ❑Casing to be Pertorat from ft to It <br /> Sealing Material Neat Cement(94 Ib bug/5- gal water)L1�O Sand Cement sack mix l 7 gal water Bentonite Pellets C A/}�,,3/ <br /> 10 <br /> ❑Bentonite(200/6 solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File 11Specs Submhtea <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> O Complete with Mushroom Cap fi below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW <br /> ,24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �t <br /> TITLE DATE SIGNED <br /> t <br /> Out t <br /> AN J <br /> 1 at- <br /> - <br /> t �., Date ,Area _ Employee IDdj <br /> Application Accepted Qy <br /> Grout Inspection y 9 <br /> Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspec ion Py_ Date Constructed Well Depth ft <br /> COMMENTS Z (] ry - <br /> PE SC Amount hec Received Date it/ Invoice# Well ID# <br /> codes <br /> Info Remitted / ash B Service Re uest# <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> snn_o02 <br />