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Job Address Cross Street APN Owner Name Phone Owner Address Contractor Phone Subcontractor Subcontractor address City/State/Zip C-57license Number Expiration Date Geographical Information:Coordinutes X Y Section Intended Use Contact Name or Phone Number New WellType Of Work Other number of borings Auger Cable Tool O Push Point Other Gravel Pack / Gravel Size in diameter in diameter ft Plastic Other Grout Placement Method DrillerPedestal Other Dimensions:ft Thick in Christy Box Submersible TurbinePump HP ft ft 7r) Signed Title Date 7^ 1 2(1)3- Application Accepted By Date Area Grout Inspection By Date Waiver ReceivedPump Inspection By Date IN.Constructed Well Depth ftDate Invoice #Well ID#Date MASTER WATER WELL PERMIT Stainless Steel Sand Cement EHD 43-02-006 12/6/2002 Well Casing Grout Seal Amount Remitted Soil Boring(s) Out-Of-Service Well Pump Repair sack mix / 7 gal water Specs Submitted C Pump Contractor Width ft Length Test Hole number of borings >AN JOaQLIN COUMT'r Destruction Inspection By COMMENTS Air Rotary ft Excavation Employee ID# Special Well Permit WELL / PUMP PERMIT aRTMENT 304 E Webek . Check/ Cash I I I I I I DEPARTMENT USE ONLY CZ) > o g rr CZ) Permit/ Remitted Service Request # Specs on File Retardant / Accelerator (name) Installed By Concrete Pedestal ____________ Township Water Quality Monitoring Stove Pipe ft Standing Water Level Range Soil Sampling/Characterization _________ ________ sc Info I LI PE Codes ^7? 'LO r Geotechnical Out-Of-Service Well Renewal Cross-Connection Repair Mud Rotary Depth ft Excavation in diameter Open Bottom Conductor Casing in diameter / Conductor Casing Depth Diameter in Thickness/Gauge/ASTM Sched Steel Depth ft Bentonite (20% solids) Pumped Received By . Cash77s/ SPECT1ONS - PLEASE CALL (209) 953/7697, Contractor Address_______ ___________________________ /M/ky ' □ D-09 □ Other Domestic/Private pi Public Water System ' If different from Owner: Replacement Well Well Alteration/Modification Monitoring Well(s) number of wells Well Destruction ________________ New Pump Pump Replacement Well Construction Drilling Method Proposed Well ZK-W/P Parcel Size -221____ )r7P ■7'77/7 EWROAMEMAL -IEA TH I llVN om Irrigation/Agricultural Industrial watCT System Name 4 MINIMUM U HOIJRApVANCE NOTICE REQUIRED FOR 1NSPEC1 __________ ____ Title _ IS Pump Set Other ft Casing to be Perforated from sack mix / 7 gal water f San Joaquin County Environmental Health L NON-Refundable Permit CALL (209) 953-7697 FOR Inspections EXPIRES 1 Year ClTY/ZlP___j Qnli/j m' l? fid APN Phone '~7 7^7______ Neat Cement (94 lb bag / 5-10 gal water) Manufacturer Spec % solids% Name Free Fall Other Other Well Destruction Open Bottom ^POravel Pack Uncased Well Diameter (jj in Total Depth 7C)& ft Depth to Water ft □ Casing to be Perforated from ft to Sealing Material □ Neat Cement (94 lb bag /5-10 gal water) □ Sand Cement 70: J sack mix / 7 gal water □ Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids . % Name, Specs.on File CJ Specs Submitted Placement Method B-fuinped □ Free Fall □ Other (Tty <7^ Q /•% I ~yi’J9((tj) ________________ Complete with Mushroom Cap ft below grade_________________Complete to Existing Surface Pad______________ I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THEf 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. e 3"l‘ Fl - Stockton CA 95202 - (209) 468-3420 r from Date Issued