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Wr lLju / rUlvlr rEK1V111 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI' "ARTMENT 304 E WEB- 'VE 3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS -XPPIIRESS 1 YEAR FROM DATE ISSUED JOB ADDRESS 10'30y CITY/ZIP '4726e,/ CROSS STREET .� �f^ / APN 0 7 tj—— RCEL SIZE OWNER NAME PHONE 1-5( OWNER ADDRESS /1` CITY/STATE/ZIP (� 1 CONTRACTOR W%!j (( .'U�+ + �`G /� ` J V (/e' 3 PHONE p CONTRACTOR ADDRESS - Od I{s C CITY/STATE/ZIP SUBCONTRACTOR PHONE �y SUBCONTRACTOR ADDRESS �q ', CrrY/STAATEE/ZZIIP 2 (' LICENSE El C-57 ❑C-61 ❑D-09 R"Other �(! Y 2 NUMBER 3�l 7/ D EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) 13 Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement Ndump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth tt Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hub/5-10 gal 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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP submersible ❑Turbine ❑Other HP_ Pump Sete ft Standing Water Level IL It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ti to ftSealing Material ❑Neat Cement(94/h hug/5-10gal wafer) ❑Sand Cement sack 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 1 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. IIM 24 HOUR ADVANCE NOTICE RElEQU RED FOR INSPECTIONS SIGNED TITLE *TPS DATE �v y Ile N O Q E DEPARTMENT USE NLY ) Application Accepted By Date Area Employee I # ( �6 Grout Inspection By Date ❑ SPECIAL Well Permit J/G Pump Inspection By `�j Date t0—7,0 ❑ WAIVER Received (� Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Amount ck#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Request# y 3 sc '0-5-1 -7-5" I3533 SD o f �j -� EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002 V