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WELL /PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -304E WEBER AVE 3M0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FDR R INSPECTIONS EXPIRES ].YEAR FROM DATE ISSUED JOB ADDRESS T - _ CITY/ZIP_ TkAe-y '9 D CROSS STREETk 40APN _-/7n -(j Z. PARCEL SIZE ZSR/r-&LAND USE AP PLICATION# A OWNERNAME r Aub AIt TI 3 PHONE 261-?36 O"ERADDRESS 3/7n TLnn`u /� IAt �Lr1T .q ccc.r�� CITY/STATE/ZIP / L — �CA 4515374 CONTRACTOR K =w �2./ 6:51 zAx, PHONE-/ZCFI CONTRACTOR ADDRESS /��F^ M /( wEs"I' /� r .r: ' lL ITX L CITY/STATE/ZIP_,FF7��'7tj ] A 1 r// II�/ 952.0�) SUBCONTRACTOR _ S [54e, ,A?jim 6Y') z)kA-now PHONE-2o?- SUBCONTRACTOR ADDRESS . 24,_15L )(•,Its 114A4 LX CITY/STATE/ZIP_ 5:="TA/1 GA 95205 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER !Pz-- ii EXPIRATION DATE Q 7 Ol GEOGRAPHICAL INFORMATION: Coordinates X Y Township 2 .S Range Section 3 �7 INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ater Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If di Rerenr from Owner-water 5Trmn Plane, onmd ame or one i,,mmar TYPE OF WORK ( ew Well El Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other monitoring Well(s)--- _pof wells ❑Soil B,rm s uof ❑Geotechnical borings Rafborings BO ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Re lacement ❑Pump Re air ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth Z$ / ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size—inISubmitted O Conductor Casing I in diameter, / Conductor Casing Depth ft Well Casing Diameter �—in Thickness/Gauge/ASTM Sched z/O ❑Steel 'lastic ❑Stainless Steel ❑Other r Grout Seal Depth /f--//! It Neat Cement(94/b bag/S-/0 ga/wafer) ❑Sand Cement ,rack mix ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Grout Placement Method ❑Pumped �,/ ree Fall ❑Other El Retardant/Accelerator(name) p PEDESTAL Installed Bv. Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width o� ft Lengthy ft Thick // in ❑Christy Boz Love Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set - ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth _ ft Depth to Water ft ❑Casing to be Perforated from_ft to - ft Sealing Material ❑Neat Cement(94 lb bog/S-/0 ga/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 1 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 COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED )7+ TITLE 15aA-1-r &OLA 7fs7 DATE 8-Aq Y7 d AL HV, DEPARTMENT U 1' N Application Accepted By Date L- Area 1 '1 1� Employee ID#1i Grout Inspection By DateI ❑ SPECIAL Well Permit Pump Inspection By Date ❑. WAIVERReceived Destruction Inspection By Date - Constructed WeI1Depth ft ('�,., COMMENTS 1 .... W m '7 -� G'P ✓ 6I'�/�� -� 01 It/ A/7fAr�1 k6tY -"V t. - PE SC ReceivedXheeld/ Amount Permit/Codes Info B Remitted Date Service Re uest# Invoice# Well ID# EHD 43-02-006 I2122n003 MASTER WATER WELL PERMIT