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d <br /> ELL / PUMP PERMIT <br /> SAN JOA LJINTY ENVIRONMENTAL HEALTH DF.PA ENT 304 E WEBER Al 4 1.-STOCKTON CA 95302 - (209)468-3420 <br /> r ON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA <br /> JOB ADDRESS Il 'I (/ / w A V Cr�✓ CITY/ZIP b—�/ A �� •��-23`6 y <br /> I' � . � � <br /> � o <br /> CROSS STREET /9 G / 1 APN PARCEL SIZE <br /> OWNER NAME PHONE <br /> OWNERADDRESS CITY/STATE/ZII' <br /> CONTRACTORM—Ae. x4 !,G PHONE <br /> CONTRACTOR ADDRESS I1 h D ✓�/ — C CITY/STATE/ZIP ` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-5761 ❑D-09 ❑Other NUMBER t% 17sz EXPIRATION DATE <br /> C- <br /> '� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> �D <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization 11 <br /> ❑Public Water System <br /> If different from Owner: Water System Name ontact ame or one um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Ilole ❑Other <br /> number of wells number of borings number of borings <br /> El Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical <br /> Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New PumE ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ti Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/b Gab/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom Gravel Pack ❑Uncased ❑Other <br /> Well Diameter 1:;' in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material Neat Cement(94 lb bag/5-10 gal water)pt v— Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑_Specs on File ❑Specs Submitted <br /> Placement Method KPumpcd ❑Free Fall ❑Other��OP r.L/ VeG <br /> ❑Complete 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. 1 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. <br /> MINIMU 24 HOUR ADVANC TICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE ©�C 1 t" DATE <br /> �. <br /> -ROP65 <br /> It <br /> 0 t <br /> �Fi�URE 4 <br /> INSi <br /> N� 0 <br /> .D ARTMENT USE ONL <br /> Application Accepted By Date y'� Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspecti n B Date 6 S �� Constructed Well Depth ft <br /> COMMENTS r <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> 8 9 : , D �3 ;eoo 3 yaz/ <br /> MASTER WATER WELL PERMIT <br /> EIID 43-02-006 <br /> t�r�r�nm <br />