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1iYn �� r 231 r �, WELL / PUMP PERMI10 SAN JOAQUIN COUNTY ENVIRONMENTALOTH DEPARTMENT 304 BER AVE 3a° FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR IISPECTIOSS EXPIRErS/ I YEAR FROM DATE ISSUED Drilling Method ❑ Mud ❑ Air Rotary ❑ Aug r ❑ Cable Tool ❑ Push Point WrOther Proposed Well Depth ft Excavation9uin diameter ❑ Open B &Xvel Pack / Gravel Size �indiaTmet in diameter / Conductor Casing Depth ft 33/ q ( JOB ADDRESS CITY/ZIP— /�../ (J "`) C3.9dPITCement sack mix/ 7 gal water 2 o 1` Name ❑ Specs on File ❑ Specs Submitted Grout Placement Method B'Pumped ❑ Free Fall ❑ Other CROSS STREET APN s_(0 PARC SIZE OWNER NAME rf / �/ ^ / �I '� PHONE WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Othfr Well Diameter in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to ft Sealing Material ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement OWNER ADDRESS Lfu U1 CITY/STATE/ZIP Name ❑ Specs on File ❑ $pees Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other CONTRACTOR ❑ Complete with Mushroom Cap ft below grade PHONE �/ ' CITY/STATE/ZIP CONTRACTOR ADDRESS / (_-/I ____SC�Y `_ L —�✓ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / D LICENSE aYe M.Gs C ❑ D-09 r NUMBER • EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates Y Township Range Nection INTENDED USE ❑ Domestic/Private rrigation/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 ❑ Monitoring Well(s) number of wells ❑ Soil Boring(s) number of borings ❑ Geotechnical number of borings ❑ W�yYDestruction ❑ Out -Of -Service Well ❑ Out -Of' -Service Well Renewal ew Pumn rl Pumn Renlacement ❑ Pumn Renair ❑ Cross -Connection Renair WELL CONSTRUCTION -- .�eci l Amount Date ash Remitted Drilling Method ❑ Mud ❑ Air Rotary ❑ Aug r ❑ Cable Tool ❑ Push Point WrOther Proposed Well Depth ft Excavation9uin diameter ❑ Open B &Xvel Pack / Gravel Size �indiaTmet in diameter / Conductor Casing Depth ft ❑ Conducto C ing Well Casing Diameter Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainl Iss St ❑ Other Grout Seal Depth It❑ Neat Cement (94 lb bag / 5-10 gal water) C3.9dPITCement sack mix/ 7 gal water ❑ Bentonite(2 %% olid') ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Grout Placement Method B'Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By 311riper ❑ Pu ueetractor ` ❑ Other ❑ Con to Pedestal Dimensions: Widtl��ft Lengt Thick in ❑ Christy Box ❑ Stove Pipe PUMP ubmersible ❑Turbine ❑Other P Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Othfr Well Diameter in Total Depth ft Depth to Water ft ❑ Casing to be Perforated from ft to ft Sealing Material ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ $pees Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Complete with Mushroom Cap ft below grade ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH TWE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSAT L S. H A E O CE REQUIRED FO N CTIONS — PLEASE CALL (209) 3-;i9 SIGNED TITLE DATE cJ% oe Application Accepted By Grout Inspection Bl Pump Inspection ld DEPARTMENT USE Date / Date Date Area Z/ "/ Employee I D# ©o f ❑ SPECIAL Well Permit ;, qv` ❑ WAIVER Received ��JJ6 Destruction Inspection By Date Constructed Well Depth ft COMMENTS T�"14:y Y 42—� Ze-,$--C799t%/81t�1o'!) �U ��r%f%�/D�rG'/1�itT_ r a•/JCtTZ Mme•.) `' i ,. ii' Q�a•-z / Mir a.- V—_ As e•.ie�y0/lf i_,� e, i_ reit, nG A.�C:"Dicey. _ /�ain �/llL'(il) ��.�.A4"";/ ) PE SC Received Codes Info By -- .�eci l Amount Date ash Remitted Permit/ a, Service Request # Invoice # Well ID# o EHD 43-02-006i� W, 5 Jam/ CtjLPCW/Vtio Ag 2� /`G��/�'� 7"�``K" a T "r 11R4A&ffM WA 1 tK WELL rrKMI I 12/6/2002