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` WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROMDATE ISSUED JOB ADDRESS 7603 Rc;Io J, e CITYIZIP C -i0A CROSS STREET APN '^/ /V—Q' 7 4 CEL SIZE 94'(0 LAND USE APPLICATION# 1COf r1Ot ,• p 0 C, OWNER NAME 'I7n/O��npso�n Q__ ! .� � 14 � PHONE faoQ- gy3�J-oQ7�i0 OWNER ADDRESS /603 .1�5.�r_�.�__ )SCA ! f CITYISTATE/ZIP 574,-c -k" /'► -JS@.j CONTRACTOR PHONE /16" 7e 5—+/�6 CONTRACTOR ADDRESS . �! /36 (/ef hall 5� CITY/STATEIZIP 03(a r/i e 9 j�b-7j' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIITY/ST�ATEIZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 40t1+ -5 EXPIRATION DATE -?10'S GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ' ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water S stein Udifferent from Owner: Water System Name Contact Name or P one Nume—r TYPE:OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a or or,Ings 1 ❑Geotechnical 0 of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 3.5 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/GaugeIASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lh hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ^� ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑free Fall ❑Other ❑Retardant/Accelerator(name) Q PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Totai Depth ft Depth to Water ft ❑Casing to be Perfo ate from ft to ft Sealing Material 11Neat Cement(94 1b hag/5-10 gal water) EISand Cement sack mix 17 gal water entonite Pellets ❑Bentonite(20%solids) M Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ryAAA Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft 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. 1 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. MIN UM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS r SIGNED T____ _ /01 i afr-v pd- 1 w i awv+ rodo1low,001 IiJ{ 'I i t I � + C,vwe +\ Uv ENT USF,ON4Y Application Accepted By (2 —, — Date t7 Z�A Area 4P-Z f Employee ID# 577 qcy Grout Inspection By Date ❑ SPECIAL Well Permit I Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received ec Amount ate Permit/ Invoice# Well€D# Codes Info B sh Remitted Service Request# 43;7i I.St- 230. n) Co03` O EHD43-02-006 MASTER WATER WELL PERMIT 12/22/2003 ti -