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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEsER AVE 30'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NGN-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> WV) M <br /> JOB ADDRESS �d ++ CITYl'Z7IP <br /> CROSS STR£ET APN C7C 0 I Q Q I PARCEL SIZE q'9 <br /> OWNER NAME PHONE <br /> ZA <br /> OWNER ADDRESS CITY/STATE/ZIP r�� �Q <br /> CONTRACTOR PHONE /w`, rZ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP L V7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS_ CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-6i _ _❑D-09 ❑Other — NUMBER EXPIRATION DATE' zna <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ❑inigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System_ <br /> ]rdirferenrfrom net Water System Name Como Nameor Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑(me r �1 <br /> ❑Monitoring Well(s) _ numberdwells ❑Soil Boring(s) numberorborings ❑Geotechnieal numberorborings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-O&Service Well Renewal <br /> ew Purnp Pump Replacement _❑Pump Repair _ ❑_C_rmg-C_o_nn_vztion Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Poiot Cl Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness(Gauge)ASTN1 Sched ❑Steel ❑Plastic ❑Stainless Steal ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-I0 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(2D%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted ry <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Retardant/Accelerator(name) G <br /> PEDESTAL Installed Bx ❑Driller ❑Pump Contractor ❑['ether - <br /> ❑Concrete Pedestal Dimensions: Width 13 Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 'Submersible ❑Turbine ❑Other HP_.-.`7 . Pump Set_tM ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack L Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to water ft O Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(201/1.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Speca Submitted <br /> Placement Method ❑Pumped O Free Fall ❑Other_ <br /> ❑Complete with Mushroom Cap ft below grade, ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAN THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULAT►ONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM 24 HOUR AD)INCE NOTIC REQUIRED FO 1 E��C�77T -PLEASE CAR L(209)9 3-7697 <br />'- SIGNED �� TITLE DATE /` <br /> G <br /> J O 1Nco <br /> �t <br /> DEPARTMENT USE LY / <br /> Application Accepted By vl Area Z1 Employee ID# <br /> Grout Inspection By Date / 0 SPECIAL Well Permit <br /> Pump Insp ytion i j Date f�� J ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth i< <br /> COMMENTS <br /> PE SC Received 712ae&W Amount bate Permit! invoice Well Codes Info B Cash Remitted Service Request <br /> :: j <br /> BHD 43-02-006 MASTER WATER WELL PERMIT <br /> 12/6/2002 <br />