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��. WELL / PUMP PERMIT SAN JOAIQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER S"0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 3 JOB ADDRESS Q / /7�I A1010 //CITY/ZIP l/f � /C/ G/k > a p I� v CROSS STREET [�D�� I` LJ APN 1�0` ARCEL SIZE14 LAND USE APPLICATION# /�j 2 OWNER NAME r)y/�Jy d t r d ` PHONE 1 �y6�v ✓oYJ OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR ` NJr&e_/) TKA -/W ' 'J °P7H�O_1N�E ✓7 CONTRACTOR ADDRESS '91o 60 (0 CITWSTATE/ZIP QvS6#" 6A . A `� Vt/Q/ �5�6 a SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ❑ her I-I LICENSE C-57 ❑C-61 ❑D-09 �., NUMBER '55oP Ci EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X 1 Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water S�stem Ifdifferent from )wner: WaterSystem Name Contact Nnmc or Phone Number TYPE OF WORK gNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole Other V& O 5 ❑Monitoring Well(s) #of wells ❑Soil Boring(s) of borings ❑Geotechnical 4 of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary llfAuger ❑Cable Tool ❑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 1 in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth It ❑Neat Cement(94/b bag/5-/0ga/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) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width tt 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 Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94/b bug/5-/0 ga/water) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted 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. 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. U 24 R ADVANCE NOTICE QUIRED OR INSPECTIONS SIGNED TITLE DATEDNY rt, (J U N D 4 - DEPARTMENT qSE ONLY Application Accepted BrQ Date 9. t Area SO Employee ID#-7�q73 Grout Inspection By 1 r tti9,�nwS Date 6 D ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received t Destruction Inspection ByL / Date Constructed Well Depth ft COMMENTS r ` ay(i DA& PE SC Received heck# Amount Date Permit/ Invoice# Well ID# Codes Info a Remitted Service Request# 00 6 T EHD43-02-006 MASTER WATER WELL PERMIT 12/22/2003