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1� WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JoLt ADDRESS -3 /47— <br /> Q7— 4 ` CITYIZIP <br /> FF {frfl A <br /> CROSS STREET 6• APN Cbc W PARCEL SIZE �7 <br /> OWNER NAME �ry11?644)Jv �//� ! L,t 4 PHONE <br /> OWNERADDRESS daCITYISTATEIZIP <br /> CONTRACTOR ////'��'�� C` /f PHONE <br /> CONTRACTOR A DD9ESS f' tJ C ITY15TA7'F1ZI P yL1■_1 <br /> SUBCONTRACTOR PHONE IP- <br /> SUBCONTRACTOR <br /> ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C-57 ❑C-6l ❑D-09 >Zher 1) �- NUMBER. 3 3 i EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE /An"omestic/Private ❑lrrigationlAgricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Charocterization <br /> ❑Public Water System <br /> If dlrrer'ent From Owner: Waier SYSLem Name Conlact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(S)__ numberorweLls El Soil Boring(s) nurnberorborings ❑Geotechnical numberofborings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump mp Reulaeement ❑Pump Repair [I Cross-Connection Repair 4� <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Poin: ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom 11 Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth ti <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Stec] ❑Other r <br /> Grout Seal Depth ft ❑Neat Cement(941h hug/5-10ged wider} ❑Sand Cement suck mb:17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Rem rdant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP bmersible ❑Turbine ❑Other HP_ Pump Set It Standing Water Level I] <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth tt Depth to Water R [JCasing to be Perforated from fl to tl <br /> Sealing Material ❑Neat Cement(941h hug/5-10 got wader) 11Sand Cement ,ruck?nix 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_._% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ti 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 COMPENSA 0 <br /> INIMUM 24 HOUR ADVANCE NOTIC RE FIRED FOR INSPECTIONS I <br /> SIGNED TITLE F DATE r �y <br /> 1.0 <br /> r i w <br /> I <br /> l <br /> t <br /> L <br /> rw O NT <br /> i M NT <br /> l� TMENT USE NLY <br /> Applic tion Accepted By 1A ! pare Area Employee lD9 r <br /> G ut Inspection.By Date ❑ SPECIAL Well Permit <br /> Pump lnspect'on By Date z ` ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE FSC Amount Chec Received Date P InVoice li Well IDA <br /> Codes Info Remitted Cash Ay e u <br /> EH 43-02.006 J I/) r f MASTER WATER WELL PERMIT <br /> 5/7/2002 <br />