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Ire') WELL / PUMP PERMIT gyp;,.tot, k`l Z!�L, Gocz- <br /> SANJOAQUINCOUNTYENVIRONMENTALHEALTHDEPARTMENT 304E WEBER AVE 3 L-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> top— <br /> JDo ADDRESS A CITY/ZIP LJO&I <br /> � o <br /> CROSS STREET QI QN• PARCEL SIZE <br /> OWNER NAME 1. <br /> PHONE <br /> OWNERADDRESS � t p CITYISTATEIZIP C � <br /> CONTRACTOR `S><! �+1�— ■y/►� rk• t• PHONE '� <br /> CONTRACTOR ADDRESS:,5` r„a P -' s� CITYISTATEIZIP ; 520S <br /> S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTORADDRE£S CITYISTTAATJFJZIP -50 �r <br /> LICENSE -57 [JC-61 Cl D-09 ❑Other NUMBER 15177-0 EXPIRATION DATE v V 0 V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Q Water Qualify Monitoring Moil Sampling/Characterization <br /> ❑Public Water S :tem <br /> If different from Owner: Water Systcra Nartic Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well 17 Well Alteration/Modification ❑Test Hole tither Z� <br /> ❑Monitoring Well(s) number of wells 13 Soil Boring(s) number or6ariog5 GimlechnlCal,� number of borings <br /> ❑Well Destruction ❑Out-Of-Servicc Well I7 Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement Q Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 15-4Q ft Excavation_I —A in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing in diameter i Conductor Casing Depth ft 11 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ih hug/5-10 gut wider) ❑Sand Cement vack rnix 17 gal water <br /> L]Bentonite(200/.solids) ❑Manufacturer Spec%solids e/a Name _ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL bstalled 8r ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Deoth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material )(Neat Cement(94 1h bag 15-10 gul wafer) ❑Sand Cement suck mix 17 gal water ❑Bentonite Peiiets <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 ft below grade ❑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. l ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 4.00-UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> _. <br /> ZZ <br /> yrf <br /> l ttI1.,4Y-s 'l <br /> _- <br /> r. - <br /> - o <br /> ro - <br /> jo Ell <br /> DEPARTMENT US NL [� <br /> Application Accepted By le Area Employee IDN 6) 1 J 19 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit T� <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By W Date ! O Constructed Well Depth it <br /> COMMENTS <br /> PE SC Amount heck# Received Date ice# Well ID0 <br /> Codes Info Remitted ash By rvice Re ues <br /> v a tt 32 W o0 <br /> EH 43-02-006 MASTER WATER WELL PERMIT <br /> 5nf2002 <br />