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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL- STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR 1\tiPF.CTIONS EXPIRES 1 YEAR FROM DATE ISSUED SC Info JOBADDRESS CITY/ZIPyQ/) Te n�`33 m Y Proposed Well Depth ft Excavation in diameter a - J1 11 o CROSS STREET APN ✓' Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel O Other %PJA�RCELoS-17ZE 6 ❑ Sand Cement OWNER NAME PHON�"' D i Name ❑ Specs on File C% �/j ❑ Retardant / Accelerator (name) OWNER ADDRESS 1 • r ' CITY/STATE/ZIP(��//� ❑ Other S E:wfSIJ ft Thick in ❑ Christy Box CONTRACTOR . NF Pump Set R Standing Water Level WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack O Uncased ❑ Other CONTRACTOR ADDRESS—215 �. CITY/STATE/ZIP t ft ❑ Casing to be Perforated from SUBCONTRACTOR PHONE sack mix / 7 gal water ❑ Bentonite Pellets SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ✓ EXPIRATION DATE eolza GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USEomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: .terSy-on Name Contact ame or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole ❑ Other ❑ Monitoring Well(s) numberofwdls 0 Soil Boring(s) numberofbonnyz ElGeotechnical number ofbormp ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal n o.. .- n r- r --i— P—q, WELL CONSTRUCIFION SC Info Received Check#/ B as Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Date Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel O Other Grout Seal Depth ft ❑ Neat Cement (94 lb hag/ 5-10 gal water) ❑ Sand Cement .cock 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 PUMPr-ySubmersible ❑Turbine ❑Other HP Pump Set R Standing Water Level WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack O Uncased ❑ Other Well Diameter in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to 11 Sealing Material ❑ Neat Cement (94 lb hag/ 5-l0 gal water) O Sand Cement sack mix / 7 gal water ❑ Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids o 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 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W1 H 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. Grout Inspection By Date ,/ ❑ SPECIAL Well Permit Pump Inspection By DateS% 07 13WAIVER Received Destruction Inspection By Date Constructed Well Depth It COMMENTSAM .4z 0 /9 9 PE Codes SC Info Received Check#/ B as Amount Remitted Date Permit/ Invoice ft WellID# Service Request # L7 C) 7t/ Sp0 E Il U, 45^ UL-UU0