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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH NWRTMENT 304E WEBER E3aa FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YIAR FROM DATE ISSUED �. io JOB ADDRESS Od C-` ;L-42z CITY/ZIP �rj 391 Y CROSSSTREET / T , APN Zoel r`tIGO-CII PARCEL SIZE gfj�j,�LAND USEAPPLICATION# A m OWNERNAMEPHONE-901-836-14-46 111 Jl^ / CITY/STATE/ZIP /— OWNERADDRESS 3J� ` y 6 •/Y<376 CONTRACTOR _ t ^••/)n L�. C.a}�^� Tf-L'f�A ArJ (KS7. AIVL `PHONE Z19-z37'C4/' CONTRACTOR ADDRESS IRR FIZAAJL� L4&Z L� L,' <11 T CITY/STATE/ZIP T)inek7aAJ- CA. q'j7�A . � SUBCONTRACTOR )064 12/JM �XAL.6j24T/AA) PHONE, d&q A65,." 717— SUBCONTRACTOR ADDRESS 23&'g LA.�/GwAM Q12. CITY/STATE/ZIP S'7TaC.J.V,1, CJI LICENSE C-57 ❑C-61 ❑D-09 13 Other NUMBEREXPIRATION DATE Q GEOGRAPHICAL INFORMATION: Coordinates X Y Township Z_5_ Range—JL& Section_ 'J INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Awater Quality.Monitoring ❑Soil Sampling/Characterization ❑Public Water System ,,,,,,,,...s/// Ifdiffemntfmm Owner: Water System Name ontaet Name., one Number ( I TYPE OF WORK New Well El Well ❑Well Alteration/Modification ❑Test Hole ❑Other Monitoring Well(s) aofborings #ofbonnas g Off#of wells O Soil Boring(s) ❑Geotechnical Well Destruction - ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other 241 Proposed Well Depth ti 215/ ft - Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R ......333 Well Casing Diameter a in Thickness/Gauge/ASTM Sched 4 0 ❑Steel Plastic ❑Stainless Steel ❑Other �1 1 Grout Seal Depth /d -I/ r. ft Neat Cement(94 lb bag/5-10 gat water) ❑Sand Cement sock mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted f Grout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By KDriller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Widthti$ ft Length 15 ft Thick rr in IJ Christy Box Xtnve Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level It 24�_ WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from it to It Sealing Material 0 Neat Cement(94 Ib bag/J-10 gal water) ❑Sand Cement sack mix 1.7 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 I 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 1 AM INCOMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIMUM 24 HOUR ADVANCE NOTICE /REQUIRED FOR INSPECTIONS SIGNED i TITLE DATE Q%A 67 Pi 01""11V U 3 Anr ef � 1 E /J " DEPARTMENT USE LY / Application Accepted By %-""' S\ Date Area f Employee[D# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS R Pn so PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# C // ✓. EHD 43-02-006 MASTER WATER WELL PERMIT IMM003