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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE <br /> {{PERMIT L // CALL <br /> /209 953-7697 FOR INSPECTIONS EXPIRES <br /> y11YEAR FROM DATE ISSUED <br /> o 3 <br /> • <br /> JOB ADDRESS L 1 a }✓j {, j S 1`O G CT1Y/ZIP V�'!11'^r i U�S 1 F"7 <br /> PARCEL SITE <br /> APN `"� 1 t�©..f-t� Po <br /> CROSS STREET (� <br /> OWNER NAME p(C - r�'r& PHONE /9.31I.� <br /> /O - <br /> OWNER ADDRESS / AJ 4 CITY/SrATE/ZIP 4.�iVT/ <br /> CONTRACTOR ev PHONE` I�!/�� <br /> CONTRACTORADDRESS I6 CITY/STATE(ZIP H'S J{— p <br /> SUBCONTRACTOR aNar�FaD PIIONE 6ey- ♦3 CII <br /> SUBCONTRACTOR ADDRESS CITY/SfATUZIP f CiMr C (fAfr1 y <br /> LICENSE 0 C-57 C-6) ❑D-09 O Other NUMBER XPIRATION DATE r <br /> GEOGRAPHICALINF'ORMAriax: Coordinates X Y Township Range Section <br /> 1NTENOED USE ODomestidPrvate R Irrigation/AgricultWal 0Industrial ❑Water Quality Monitoring 0 Soil Sompling/Chaiocusi7an <br /> Cl Public Water Svstcm _ <br /> lttliit fiarn ilwner. -' .ter ysrem me P�v ore um <br /> TYPE OF WORK 0 New Well 0 Replacement Well O Well Alteration/modification O Tett Hole O Other <br /> O Monitoring Well(s) nmbeow"1 oorngs) 13 Gantechnical —benraorin0 <br /> v <br /> O Well Destruction 0 Out-Of--Service Well 00.t-Ot=Servi:.Well Renewal <br /> O New Pump OPurapPcplaccatem A llrum R it O Cmes-Connecdon Repair <br /> WEIA.CONSYRuctrION <br /> Drilling Method 0 Mud Rotary C3 Air Rotsry O Auger O Cable Tool O Push Poini O Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom 0 Gravel Pack/Gravel Sia - Idiam-eftr❑ConductorCasingindiameter / Conductor Casing Depth ____tlWell Casing Diameter_in Thickness/GaugGASTM Sched_ O Steel fl Plvstic 0StinlessSteel 0 Other <br /> Grout Seal Depths ft O.Neat Cement r941b bug/5.10 gal wafer) 09iand Cement sack mix lgewater � <br /> O Bentonite(200/,Solids) 0 Manufacrurw Spec%solids_,% Name_ 0 Specs on File, 0 Specs Submitted <br /> Grout PI cement Method 0 Pumped O Free Folf 0 Other 0 Retardant/Accelerator(name) _ <br /> PEDESTAL Installed By O Driller 0 Pump Contractor 0 Other <br /> O Concrete Pedestal D'imenslons: Wit Wt_ 11 Length_R Thick in Cl Christy Box O Stove Pipe <br /> PUMP 0 Submersible ATurbine ❑Other__ HP__ Pump Sci ft Standing Water Level R <br /> WELL Dii;muCTION 0 Open Bottom 0 Gravel Pack 0 Unceaed 0 Other <br /> We]]Diameter in Total Depth ft Depth to Water_ ft 0 Casingto be Perforated from tt to fi <br /> Seating Material E3 Neat Cement(94/6 log/3-10 gal water) 0 Sand Cement sac*raiz/7 gal water 0 Bemnnitc Peter. <br /> O Bentonite(20%solids) O Manufacturer Spec%.solids % Name O Specs on File O Specs Submitted <br /> • Pheeemeut Method 0 Pumped O Free Fall ❑other <br /> O Com with Mushroom trap_..._H below grade_ O Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS.APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE.LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL. <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> 4-� L <br /> M <br /> R <br /> EPARTMENTUSEO LY <br /> Application Accepted By Area , Employee 10q <br /> Ganm Inspection By Date O�SPTECCIIAL Well Permit 7 <br /> Pump Inspection Dem , <br /> �Q ❑ WAIVER Received <br /> Destruction Inspe:titm By _ Date Constructed Well Depth B <br /> COMMENTS <br /> -9 <br /> PE SC Amount heck#1 Received Y <br /> Codes Info RemittedB Date rvice Re seat Invoice# Well IDN <br /> L <br /> • EHD 43-02-006 <br /> 517!'.A02 MASTER WATER WELL PERMIT <br />