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"'. WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> I NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ^� ��}} JJ� r rn <br /> 76o, ,-Doc �. 0 it Cao � - CITY/ZIP .-7thCt 4In <br /> JOB ADDRESS 1 > <br /> a <br /> � �! v <br /> CROSS STREET q Q� rfAPN lj /yJ"I /jr�—0� PARCEL SIZE T~" LAND USE APPLICATION# )C*1' -% <br /> �Q•llr+wl aG //7 -7 <br /> OWNER NAME �D+hA-so''1 _ _ _. PHONE o�74' Q 7 J"'C�/ 6 0 <br /> OWNER ADDRESS <br /> f�1�-3 �1gGt _ [t CITYISTATEIZIP <br /> Q/` ^� <br /> CONTRACTOR FO d4 ��fL L//P7HpNE [rV ���,Q6 -' 5`,),, <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS �(J V V eI hOl�t �� CITYISTATE/ZiP /5 O-s a-y a Ay_ � / �✓��� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 40PS-5-5 EXPIRATION DATE d�S <br /> GEOGRAPHICAL INFORMATION: Coordinates X - V Township Range Section <br /> INTENDED USE ❑Domestic/Private ©Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ,jli=❑Replacement Well ❑Well Alteration/Modification Test Hole ❑Other <br /> #of borings ❑Geotechnical H of borings <br /> ❑Monitoring We11(s) #of wells [3 Soil Boring(s) <br /> i]Well Destruction ❑Out-Of Service Well CC <br /> W.177 ker( <br /> E EI <br /> :1 ❑Pump ❑Pump n� tioe & <br /> ❑New Pum <br /> WELL CONSTRUCTION - <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Too] ,��IRtu �Pi-nt �l ! h �Tar} veli}hnl l} <br /> Proposed Well Depth ft Excavation in diarneter p.,n ottom ul {]Gr e Pa /Gravel Si a ,. in diameter <br /> ❑ConductorCasing in diameter / Conductor CasingDepth �� '�� capee�'`ar irEs } I�LCLI <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑S4 ,�.-Civumt-t inn stWi u4th lb.QaWn <br /> Grout Seal Depth ft ❑Neat Cement(94 th hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall O Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By 1� ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> 1 PUMP ❑Submersible 17 Turbine ❑Other HP Pump Set ft Standing Water Level ft r/] <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> W in T D Dept P <br /> e fo _ <br /> Se 'ng Materia ❑N t C t(44 g/ 0 ba! er) ❑S CementX <br /> to ReE <br /> F ❑ (20°/ 1 ) a acturer ec%solids ❑ b tedPine ent Metho ❑ pe re all ❑Other❑ mplete shr C ft below gradff ti 5u <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. � r • <br /> MIN UM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /f <br /> `SIGNED TITLE f T (,S/ DATE <br /> ii PROPOS4A <br /> 2t0'd0 <br /> ,iPRORPOSIMI <br /> too•IIt N--ME IyP� <br /> i1 ` <br /> 16 <br /> G <br /> � <br /> I <br /> Application Accepted By ti �� Date Area ^ 04 G Employee ID##✓`1�� g <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Rec'eiv'ed <br /> Destruction Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received heck# Amount ate Permit] ]Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> EHU 43-02-006 MASTER WATER WELL PERMIT <br /> 12/2212003 <br />