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WELL / PUMP PERMIT vSANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBERAVE3M°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 OR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED m / CITY/ZIPy JOB ADDRESS O CROSS STREET �- LI'flnwl 1LO�AAPN Z49_036 - 0.3 PARCEL SIZE S�LAND USE APPLICATION# n ' on OWNERNAME J.stz.OI4 C41 k4i a wnf-4 PHONE 7o9,t-2✓N I:E� y OWNERADDRESg 7121) - aL4�J.tl�/ Till rr=4 - CITY/STATE/ZIP IZA LV- 376 CONTRACTOR i1-fr -"I ASI+ -t/� 1--�1�%f} PHONE .2�-Lj4'OSIX CONTRACTOR ADDRESS /21 FJa '1✓ W&ST ! -1Q:C.LFs �ItIT�` 3- CITY/STATE/ZIP STCX-X7aA11 (' q5 SUBCONTRACTOR T'S��LTIi:IJ 1'In �YI�L^Pd7i,_, Jl / PHONE Z,91--2/45-9?Y2 SUBCONTRACTOR ADDRESS Z"'Ak r• I,i „sw /,2 CITY/STATEIZIP 1LT71Al. IfA LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBE0. EXPIRATION DATE O 0 GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township , _ Range—JL—f, Section-33- INTENDED ection-33INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ;k*laler Quality Monitoring ❑Soil Sampiing/Charscterization Q-- 0 ❑Public Water System Ifdifferentfma Owner. stir ystem ame - Doted Name or one um er q TYPE OF WORK g'New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other V 1 N of borings 13 Geotechnical a of borings F'Monitoring Well(s)�#of wells ❑Soil Boring(s) ❑`Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair - ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger .D Cable Tool ❑Push Point - ❑-Other Proposed Well Depth 111'l' 215 y ft Excavation in diameter `. ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing. in diameter / Conductor Casing Depth ft 0 Well Casing Diameter Z/1 in Thickness/Gauge/ASTM Sched 40 ❑Steel )4iastic ❑Stainless Steel ❑Other /fft Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water Grout Seel Depth p-$1�F n!/ A . ❑Bentonite(20%solids) 13Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) _ PEDESTAL - Installed By V<Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: WidthNy ft Length n ft Thick _ in ❑Christy Box Stove Pipe. PUMP ❑Submersible ❑Turbine . ❑Other HP Pump Set ft Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth _ ft Depth to Water ft Cl Casing to be Perforated from R to ft Sealing Material ❑Neat Cement(94 Ib bag/5-10gal water) ❑Sand Cement sack 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. I ALSO CERTIFY THAT MY REQUIRED-LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COC9PLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIMUpM�24 �HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS p SIGNED / i�� /�/�^`` C'• �-A�'I I�Z TITLE :�7A F'F C 7LLBLDI '/1 SY DATE S A C f .7 r DEPARTMENT USE .777 Application Accepted By Date Area Employee ID# /-y Grout Inspection By - Date ❑ SPECIAL Well Permit -7 Pump Inspection By Date - ❑ WAIVER Received Destruction Inspection By Date •Constructed Well Depth It COMMKTS E r?40F , 119111&1 A#L4PV11j ^t' MK/ a'L IN 4 PE SC Received hec Amount - Dite - Permit/ Invoice# WgII ID# Codes Info 6 ash Remitted Service Re uest# <00 39 t END 4341-006 MASTER WATER WELLPERMIT Ilrslrz003 .. ,. .