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I <br />WELL / PUAIP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3`DFL- STOCKTON CA 95202 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOBADDRESS CITYIZIP <br />CROSS STREET PN 5S/ — 32-0 ^ OkYARCEL SIZE �� 43 LAND USE APPLICATION # { <br />Q L - <br />OWNER NAME V" PHONE <br />OWNER ADDRESS CITYISTATE/ZIP ` 2 '� Was <br />CONTRACTOR PHONE <br />CONTRACTOR ADDR1rSS CITYISTATEIZIP <br />SUBCONTRACTOR PHONE <br />SUBcolt[\rRAGTOR ADDRESS <br />Lic ;E C-57 ❑ C-61 ❑ D-09 ❑ O <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />CITY/STATE/ZIP <br />NUMBER qO //r3J EXPIRATION DATE -31^O <br />Y TuWmhln R.. a tv...r.,.. <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural p Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />[fditTcrcnt from OLLner. mer ystem mne oract imeor no u cr <br />_ _. _ _......... ..�N,..,.:,,,m. Wc„ u Wet nucranonrmoatncanon u Test Hole ❑Other <br />Ll Monitoring Well(s) flofwells a Soil Boring(s)# of bonngc <br />❑Creotechn#orborin <br />ice] p <br />O Well Destruction^ 0Out-Of-Service Well O Out -Of -Service Well Renewal <br />n v 1 v„__ <br />uunactlon tc atr <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth B 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 lb bag /5-10 gal water) O Sand Cement sack mix / 7 go] water <br />❑ Bentonite (20'/a solids) ❑ Manufacturer Spec o/a solids _% Name C) Specs on File O Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By O Driller ❑ Pump Contractor O Other <br />❑ Concrete Pedestal Dlmeaslons: W'idtb_ ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Sct ft Standing Water level ft <br />WELL DESTRUCTION Q Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Diameter _in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to ft <br />Sealing Material ❑ New Cement (941b hag/5-10 gal water) ❑ Sand Cement sack mix / 7 gal water O Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method O Pumped ❑ Free Fall ❑ Other <br />❑ Complete with Mushroom Cap ft below grade ❑ Complete to Existing Surface Pad <br />crnrsau rn4) ArrLICAIION AND IHA'I'IHE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />RDINCE <br />JOAQUIN COUNTY ONAS, 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 />MINIM 24 OUR ADVANCE NOTICE AEQUIRED FOR INSPECTIONS <br />SIGNED <br />TITLE Halt,DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump inspection 41 <br />Destruction Inspection By <br />COMMENTS <br />itrGPll VJ VN Y r1r-r'"-"' <br />Date 23 17 t Area EmployeefD# cS-> �'� <br />Date ❑ SPECIAL Well Permit <br />Date /, i, Y,^.{/ ❑ WAIVER Received <br />Date Constructed Weil Depth It <br />PE SC <br />Codes Info <br />Received Check#! <br />B as <br />Amount Dale <br />Remitted <br />Permit/ <br />Service Request 4 Invoice# Well ID# <br />43-92- <br />U-9 <br />sa t o <br />'71 <br />DUD 43-02-D06 <br />122]/29D3 <br />MASTER WATER WELL PERMIT <br />