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WELL / PIUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEAAARTMENT 304 E WEIROAVE 3M' FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT t CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9, CITY/ZIP 5T " `) / a <br />CROSS STREET APN 2-0 <br />OWNER NAME � I` I'A y PHONE <br />PARCEL SIZE <br />OWNER ADDRESS 'p CITY/STATE/ZIP �j l/� <br />CONTRACTOR C(4-" L& W & � PHONE L162 —) <br />CONTRACTOR ADDRESS CA& IW& WA U CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS A CI.T/7Y/`STATE/ZIP <br />LICENSE C- ax --64 ❑ D-09 Qofier NUMBE / ` EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different fromOwner:Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole ❑ Other <br />❑ Monitoring Well(s) number of wells ❑ Soil Boring(s) number of borings ❑ Geotechnical number of borings <br />❑ Well Destruction / ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />r-1 rm.., D....,., M.P,,.. Q -1--t rl %­ Rrnair fl Crncc-Cnnnectinn Rennir <br />WELL CONSTRUCTION <br />heck#/ <br />as <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter <br />❑ 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 <br />❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag / S-!0 gal water) <br />❑ Sand Cement suck mix / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length <br />ft k in ❑ Christy Box ❑ Stove Pipe <br />PUMP M86mersible ❑ Turbine ❑ Other HPump <br />Set ft Standing Water Level ft <br />WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased <br />❑ Other <br />Well Diameter in Total Depth ft Depth to Water <br />ft ❑ Casing to be Perforated from ft to ft <br />Sealing Material ❑ Neat Cement (94 lb hug / 5-10 gal water) ❑ Sand Cement <br />sack mix / 7 gal water ❑ Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Complete with Mushroom Cap It below grade <br />❑ Complete to Existing Surface Pad <br />1 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE SATjQN LAWS. <br />MI UV�U)CADVhNCE NOTICE REQUIRED FOf ASPECTIONS — PLEASE CALL (209 <br />SIGNED v // TITLE 11rrI/ DATE YY <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Destruction Inspection By <br />COMMENTS <br />Date <br />Date <br />T <br />Area — Employee ID# V Q <br />❑ SPECIAL Well Permit�� <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info By <br />heck#/ <br />as <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />q3 a- <br />o s3-7 <br />EHD43-02-006 MAJIrK WAItK WCLLrrKM11 <br />12/6/2002 <br />