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n WELL 1 PUMP PERMIT n l� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIfDEPARTMENT r 6 304 E Wt.-,q Avg 3"'FL-STOCKTON CA 95202 - (209)468-3420 X00 NON-REFUNDABLE PERMIT CAJA 209 953-7697 FOR INSPECTIONS EXPIRES 1/YEAR FROM DATE ISSUED i JOB ADDRESS C W ' CITY/ZIP y CROSS STREET I jk�/44u- A N DI l PARCEL SIZE f ' 7�a �3 Z, OWNER NAME '- PHONE {J OWNER ADDRESS 12 CITY/STAT CONTPACTOR rryr 4s� �Sr I/ E . 7Z CONTRACTOR ADDRESS z� ��f CITYISTATEIZIP --5 ]Q_ SUBCONTRACTOR J/ I tIPR JJJOINE C.7C] ^ SUBCONTRACTOR ADDRESS aq CITYISTATEIZIL1 ti+l / �/ -7 LICENSE C-57 C-61 ❑D-09 ❑Other NUMIER EXPIRATION DATE f GEOGRAPiIICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System if different from Owner: Water System Name Comact Norrie or Phone Nuinbcr TYPE OF WORK New Well ❑Replacement Well ❑Well Alteralion/Modification ❑Test Hole ❑Other number of wel Is number of borings number of borings ❑Monitoring Wells) ❑Soil Boring(s) E3 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 XMud Rootarryy�} + ❑Air Rotary ❑Auger 13 Cable Tool ❑Push Point ❑Other Proposed Well Depth 'I 'oii� ti Excavation� in diameter ❑Open Bottom Gravel Pack I Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth R Well Casing Diameterin Thickness/Gauge/ASTM SchedV ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth A91*)—tt ❑Neat Cement(941h brig/5-10 gal wider) ❑Sand Cement sci k mix 17 gal water 043entonite(20%solids) ❑Manulacturer Spec%solids % Name ❑Specs on hilt ❑Specs Submitted Grout Placement"Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length_2=n—ft Thick in ❑Christy Box ❑Stove Pipe PUMP submersible ❑Turbine ❑Other HP Pump Set /Y4�7 11 Standing Water Level ---FL49 ti a WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncesed ❑Other j Well Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hug/5-1 d gal wider) ❑Sand Cement sack+nix 17 gal water ❑Bentonite Pellets i ❑Bentonite(200/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ti 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 COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. N14NIMUNI 24 [IOUR ADVANCE NOTICE UQUUIIRI;[),I�OIZy INSPECTIONS SIGNED / �'-`-1 TITLE /-i'!�E� L � LO IL G ' Ole. SA JC A i 71E DEPARTME T �/O LY J Application Accepted By e D e es r � -Z— Area_! Employee 1D# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By A Date ) _ ❑ WAIVER Received,,..,, pp,�.�� Destruction inspection By Date !� Constructed Well Depth l-eh ft COMMENTS ��` PE SC Amount r, Check4V Received Date Permit! Invoice# ' Well ID# Codes Info Remitted By Service Request# d Zz a - 3a 1) 346030144 56 t 5P-40 I& HHD 43-02-006 MASTER WATER WELL PERMIT j 5/7/2002 j