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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENViRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3MP FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 4CALL 09 953- 97 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> r <br /> JOB ADDRESS Allen CITY/ZIP 25�d/ / _ a <br /> o <br /> CROS-3 STREET APN a2 <br /> XS' -- PARCEL SIZE r <br /> OWNER NAME PHONE / r+ 9— <br /> Owmt AnbitE85 e? t CITYISTATEIZIP �CJ��^^� / �jv�rr�S}C�r <br /> CONTRACTOR r C , PIIONE�2�C z <br /> CONTRACTOR ADDRESS L �` _ CITYISTATEIZIP J Q <br /> SUBCONTRACTOR_ PHONE. <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP ++�� <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 2..- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ❑Irrigatioa/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> IF different from Owner Waier SYSLem Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Welt ❑Replacement Well ❑Well AlteretiorlModificatian ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) numberofwetls ❑Soil Borings) numberofborings ❑Geolechnlcal nurr6crorborings <br /> ❑Well Destruction El Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> Q New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTIO <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth AM ft Excavation_ Z in diameter ❑Open Bottom Gravel Pacts i Gravel Size in diameter <br /> ❑Conductor Casing sr diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in ThickneWGaugeIASTM Sched 1,g;�!g ❑Steel astic ❑Stainless Steel ❑Other <br /> Grout Seal Depth jd5V It ❑Meat Cement(941b hug/5-10 gal tearer) ❑Sand Cement suck mix/7 gal water <br /> V entonite(20%solids) 0 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method mped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDIESTAL Installed By ❑Driller mp Contractor 0 Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ti Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level tt <br /> _ WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft t7 Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lb hag/5-10 gal wider) ❑Sand Cement suek rues 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids—__% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall CJ Other <br /> ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad <br /> l HEREBY CERTIFY THAT 1 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE l5 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> { MINIM 4 HOUR ADVANCE NOTICE FEQUIVED FOR INSPECTIONS <br /> SIGNED TITLE N DATE <br /> AA 7 <br /> I §1A <br /> u <br /> DEPARTMENT USE O Y (� <br /> Application Accepted B. Date o Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Ir <br /> Pump Inspection By Hate ❑ WAIVER Received <br /> Destruction inspection By Dale / 00 Constructed Well Depth ft <br /> COMMENTS g ` <br /> ® OL <br /> PE Sc Amount Check#/ Received 617 Date AfPermit/ Z Invoicel♦ well1D,tl <br /> Codes Info Remitted Cash By a st S <br /> P-2 6� a o0 ZLF <br /> Log efi <br /> op <br /> EliD 43-02-006 � Sr�1� Y �ae<' 7� MASTER WATER WELL PERMIT <br /> 517/2002 �/ r <br />