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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a FL-STOCKTON CA 95202 - (209)468-3420 NON-REF-, ABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED to -ht wellcjh�uP q.533(9 JOB ADDRESS CITY/ZIP m /^y a CROSS STREET APN q I� PARCEL SIZE A OWNER NAME lsf PHONE / �yuf � OWNER ADDRESS 7 7-577 A�&&J CITY/STATE/ZIP L,� CONTRACTOR LL- PcRONE CONTRACTOR ADDRESS CITY/STATE/ZIP S77 D SUBCONTRACTOR PIIONF. SUBCONTRACTOR ADDRESS CITY/STATE/ZIP y`�/ ��//ff LICENSE E11,47 -61 ❑D-09 ❑Other NUMBER/I EXPIRATION DATE V GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irr/i�a�io Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Public Water System U 4AT4r6'0 ��- If different from Owner: WaterSystemName I Contact Name or Phone Num er �G t� TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings C3 Monitoring Well(s) ❑Soil Boring(s) _ ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCI'ION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other Proposed Well Depth 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/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth fl ❑Neat Cement(94 lb hub/5-10 gal water) ❑Sand Cement sack mix/7 gal water -rte ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted j Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) 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 ❑40eBottom � �❑Uncased ❑Other Well Diameterto Total Depth tt D�eppt/th,to Water ft ❑Casing to be Perforated from ft to ItScaling Material ❑Neat(94 lh hug/5-10 gal water) SO<and Cement_ uc•k mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Methods� ❑Pumped ❑Free Fal ❑Other p�Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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. MI 2 O C T E REQUIRED FV1 PE I,ONS- PLEAS/FALL(2099))95/7697 SIGNED TITLE �/ �/ DATE 1A A /N' I c + ±- i= C -- 5A J' M-7111C, J1141 I S 21 L),I'l tLuLdI(,E l`. w-r]rot la l r lo-:l l lU IT 6!J,: 21 1� DEPARTMENT USE Application Accepted y Date 7 Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ll`` Date ❑ WAIVER Received Destruction Inspection By -l�/ Date y Constructed Well Depth ft COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# EHD43-02-006 MASTER WATER WELL.PERMIT 12/6/2002