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SWELL 1 PUMP PERMIT - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D,_,.RTMENT 304 E WEBER, .31O FL-$TOCKTON 20 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED / H JOB ADDRESS CITYIZIP CROSS STREET f �L) APN © PARCEL SIZE ' � y PHONE-01F,3_111-4 — OWNERNAME OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR _ Cr�n//l� Lf� � PHONE CONTRACTOR ADDRESS /ll �J ! G� CITYISTATEIZIY SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZI P O J�7 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE Ci^~ LICENSE .� GEOGRAPHICAL INFO ATION: Coordinates X Y Township Range Section i,;:. ` INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chaianterization ❑Public Water System Name or oneum Number Vdifferent from weer: Water ystem Name ontact TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings 13 Monitoring Well(s) ❑Soil Barings) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Re lacement .❑Pump Repair ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method 8 ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool 0 Push Point ❑Other Proposed Well Depth Jj:�4 ft Excavation I/ in diameter ❑Open Bottom B'C'ravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter eY in Thickness/Gauge/ASTM Sched JjZ— _ ❑Steel Plastic ❑Stainless Steel 0 Other Grout Seal Depptth— wo ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement .rack mix 17 gal water 1-Bentonites(200 solids) ❑Manufacturer Spec%solids % Name �� s on File ❑Specs Submitted Grout Placement Method 8 Pumped ❑Free Fall 13 Other Q Retardant 1 Accelerator(name) PEDESTAL Installed By ❑Driller P-Kmp Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other IIP 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 Cl Casing to be Perforated from ft to ft I Seating Material ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix 17 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENS TION LAWS. I 24 HO ADVANCE NOTICE REQUIRED FO SPE TION�LEASE CALL(209)953-7697 SIGNED TITLE DATE AV I I.LO LIE li 0 F DEPARTMENT USE NLY e Application Accepted By _ Date Area Employee ID# Grout Inspection B Date — —0 ❑ SPECIAL Well Permit t Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date 1Constructed Well Depth It COMMENTS PE Sc. Received Check# Amount Permit! Codes Info B as Remitted Date Service Request# Invoice# Well ID# 9 EH 43-02-006 'Vo2,0 MASTER WATER WELL PERMIT 12/6/2002