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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WFBFR AVE 3k°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CRI CITY/ZIP� �� _ > CROSS S'TRF.F.T KASS'(J RQ A P N r4TL[i[! PARCEL SIZE o OWNERNAME f /,7�/ PHONE ,�+ y� 'rn' OWNER ADDRESS �f'�' CITYISTATEIZIP TJ�A � � 7M3 //ir- CONTRACTOR _ ,1 L PHONE 7 f7 CONTRACTORADDRESS V CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITVIISTTA�TErIZII�P r� LICENSE YJ 1;-37 ❑C-6I ❑D-09 ❑Other NUMBER�c7�L!p EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USF. ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring C3Soil Sampiing/CharaCterization --7 - ❑Public Water System If different from Owner. ater ystem -ami CuntaCL Name m Phone Number TYPE OF WORK W ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test I iole ❑Other (711 ❑Monitoring Well(s) ___ number o ❑Sail Boring(s)f wells number of borings ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump R air ❑Cross-Connection Repair WELL CONSTRUCTn� Drilling Method P*Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑Push Point "'❑Other Proposed Well Depth _R Excavation____._// in diameter ❑Open Bottom IlGravel Pack/Gravel Size in diameter 13 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter —,�— � in Thickness/Gauge/ASTM Sched 0 13_ Steel IV lactic ❑Stainless Steel ❑Other Grout Seal Depth /190 ft ❑Neat Cement(94 lh hag 15-10 gat wader) ❑Sand Cement sack mix/7 gal water B') ntonite(20�°°solids) ❑Manufacturer Spee°1°solids 2�% Name {r� /}y pots on File ❑Specs Submitted Grout Placement Method B'Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller 21rump Coatractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other _ We]]Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ElNeat Cement(94 lb hug/5-10 gal water) ElSand Cement suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. l ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. U 24 TUR ADVANCE NOTICE REQUIRED FO NSPif,frTIONS--PLEASE CALL(209)953- 697 IGNED TfTLE DATE 4 PAyivi 77 , ri Ap L2 OHL- NVI i)7u;`•t�'.f,- ,I. -:]` li°''!S1 P. — EPAR MENT U E ONLY Application Accepted by �` ' Date �-1-: 6 Area Employee ID# NZ Grout Inspection By Daterr ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS �f d PE SC Received Check#! Amount Permit! Codes Info B s Remitted Date rvtce e u Invoice#F Well IM EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002