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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 <br /> NON-REF't_INDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rA <br /> Z ���� LCA4hrof q 533D <br /> JOB ADDRESS CITY/ZIP m <br /> a <br /> e <br /> CROSSSTREET APN (r1�� ! y PARCELSIZE <br /> 90 OWNER NAME + At 1J' JPNONE <br /> OWNER ADDRESS CITY/STATEIZIP LA <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP �977/1! [ Q <br /> SUBCONTRACTOR PHONE T� <br /> SUBCONTRACTOR ADDRESS,.. �CCIITYiSTATEIZIP P <br /> LICENSE I�C-57 LMC-b1 13D-09 13 Other NUMBER) /' EXPIRATION DATE v <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Ir- 1i° Agneultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization S'P <br /> Pubhc Water System {f{ Tb} b� 4AT41f� Z <br /> IrdifFerem from nen �$ystemontacr Fame oe one um r <br /> i <br /> — — — <br /> 0 <br /> TYPE OF WORK ❑New Weil ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) _ numberofwens Q Soil Boring(s) numberofboeings ❑Geotechnical numberofborings <br /> 13 Well Destruction ❑Out-Of-Seryice Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump R lacement _ ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation_ in diameter 0 Opcn Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter in ThicknesslGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94th hug/5-10 gal water) ❑Sand Cement suck mix 17 gal water - ~ <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted G <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width t, Length ft Thick in 17 Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑4cer <br /> Bottom ci PP C Uneased ❑Other <br /> Well Diameterto Total Depth ft Depth to Water � R ❑Casing to be Perforated front R to It <br /> Sealing Material ❑Neat(94 lh bag/5-10 gu!water) C�}'Sand Cement/�J S sack mux/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(201/'o solids) ❑Manufacturer Spec%solids__% Name ❑Specs on File ❑Specs Submitted <br /> Placement Methoo�d// ❑Pumped ❑Free Fal El Other <br /> a'L:omplete with Mushroom Cap ft 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI 2 O E REQUIRED FO f PE �IONS-PLEASA9) 5 -7697 <br /> SIGNED TITLE DATE <br /> ECE 7T, <br /> F •i <br /> ZA <br /> T i <br /> t�l <br /> L1 I <br /> DEPARTMENT SE 011iM)i <br /> Application Accepted' y Date lU r� Area lam{(�- Employee ID# �8ap <br /> Grout inspection By Date ❑ SPECIAL Well Pertllit <br /> Pump Inspection By / Date 13 WAIVER Received <br /> Destruction Inspection By W, _ Date �l Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Amount DateInvoice# Weil ID# <br /> Codes Info 13 Cash Remitted Service Req nest# <br /> o� r_111l1 P <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 12/612002 <br />