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WELL / PUMP PERMIT y85�8 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn Jas ADDREssfa.T /YICt t yr otrl ve CITYIZIP C M a n y �' / C-7 v CROSS STREET 116 f l 1/j l7 �/ APN - J�F�~t PARCEL SIZE .2.` 7 LAND USE APPLICATION# OWNER NAMEC /fit �"�✓7-03� �� -_4„T_ Q � �IFrL C.02Lf��1✓y PHONE OWNER ADDRESS CITY/STATE/ZIP �rQ� 4 9.5,374, CONTRACTOR /�j, C / . .._ _ PHONE - CONTRACTOR ADDRESS //2, O?y E jWtIr/l.�I e J�. CITY/STATEIZIPIf SUBCONTRACTOR —QWU PHONE SUBCONTRACTOR ADDRESS CIT //Y/STATE/ZIP LICENSE AWC-57 ❑C-61 ❑D-09 ❑Other NUMBER �tp 742 Sok EXPIRATION DATE �2 I GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑DomesticlPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring AtSoil Sampling/Characterization ❑Public Water System If different from Owner Water System Name onlact ame or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other j ❑MonitoringWells #of wells ❑Soil Boring(s)- afborings #of borings { ) �I'Geotechnica] ❑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 RAuger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth -�� ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter i ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainiess Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water j ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name p V I JWSpecs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/ ccelerator(name) r PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other v, ❑Concrete Pedestal Dimensions: Width ft 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 .S Sealing Material ❑Neat Cement(94 Ib bag/S-!0 gal water) ❑Sand Cement .rack mix 17 gal water ❑Bentonite Pellets 11 ❑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 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN tt� JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS P� CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIINNIM24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED C TITLE , DATE p i AN 4-1 1111 i I= � i I DEPARTMENT USErONT Application Accepted By Date 2`f Area f Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit / Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft I COMMENTS PE SC Received Check#/ Amount pate Permit! Invoice# Well ID# Codes Info B Remitted Service Request# 43,77- !s.v L.-I 74 2-W.Lo O 31 9 3 40 a21 3 F/,g EMD 43-02-006 MASTER WATER WELL PERMIT 12,122/2003