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ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE TALENT 304E WEBER*11 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 2�6 �yH/ Pte_ JOB ADDRESS ( CITY/ZIP m a CROSSSTREET APN ARCELSIZE V OWNERNAME i•��a/ Y p „� '� PHONE y OWNERADDRESS R moiCITY/STATE/ZIP CONTRACTOR d c PHONE W 26—C- --132 CONTRACTOR ADDRESS Pa 13P/ vil CITY/STATEJZIP ZSUBCONTRACTOR �. r PHONE SUBCONTRACTOR ADDRESS �� /l CITY/STATE/ZIP LICENSE 7 - 1 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IfdilTemnt from wnec Water System Name C.msst ame or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells ❑Soil Boring(s) numberofbonngs ❑Geotechnical numberofborings ❑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 Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/J-l0 gal water) ❑Sand Cement ,sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ A Length_H Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other His Pump Set _ Il Standing Water Level Il WELL DESTRUCTION ❑Op n Bottom vel Pack ❑Uoased__ OOther Well Diameter in Total Depth � Il Depth w WAler Il ❑Casing to be Pcriistawd from _ B to 11 Sealing Material ❑Neat ement(94IAhag/J-10 gal water) 0 Sand Cement m<A m¢/7 gal watcr ❑Bcntomte elleta ❑Bentonite(20%solids) ❑Manufacturer Spec%solids—el, Name C3Specs on File O Spats Suhmuravl Placement Method ❑Pumped [IFree Fall ❑Other ❑Complete with Mushroom Cap Il below grade O Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WtTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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. DEPARTMENT U 'LY Application Accepted By � Date D Area O) (� �tf�Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date lD �3 Constructed Well Depth it COMMENTS 2/AIQ u.a PE SC Received ChecW Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Re uest# b D' O p EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002