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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL ePARWELL / PUMP PERMIT <br /> NON-REFUNDABLE PER IT TMENT 304 E W£BVE 3N FL.STOCKTON CA 95202 - (209 468-342 <br /> !k CALL.{209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED o <br /> { 7ADDRESS LII5-7 <br /> w CITY/ZIP <br /> PN _QPARCEL SIZE <br /> .� � <br /> \ 1 PHONE <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR <br /> . � <br /> CONTRACTOR ADDRESS Q � ` G, PHONE ' <br /> CITY/STATE/ZIP <br /> c� fln <br /> SUBCONTRACTOR k i I j5 r <br /> SUBCONTRACTOR ADDRESS ` <br /> v L <br /> CITY/STATE/ZIP <br /> P <br /> LICENSE 13C-57 1-1 C-6l 13D-09 !, �' <br /> Other ZS d NUMBER 7'3�Qt3�. EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X a 3� <br /> F ' Y Township <br /> INTENDED USE omestic/Arivate [III rigation/Agricultural ❑Industriai ❑Water Quality Monitorin Range Section <br /> ❑Public Water System g ❑Soil Sampling/Characterization <br /> If different from Owner: ager ystcm ame <br /> omact ame or one Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well 13WellAlteration/Modification ❑Test Hole Other <br /> I 0 Monitoring Well(s) ` number of wells <br /> C1Soil Boring(s) number of borings <br /> ❑Well Destruction t 13number of borins <br /> g Geotechnical <br /> ❑Out-Of-Service We[i ❑Out-Of-Service Well Renewal <br /> ' !9 New Pum m Pum Re lacement ❑Pum Re air <br /> �WELLNSTRUCTION ❑Cross-Connection Re air <br /> ethod ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Well Depth ft ilExcavation� in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size <br /> ❑Conductor Casing I in diameter / Conductor Casing Depth ft in diameter <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched <br /> ❑Steel ❑Plastic Cl Stainless Steel 13 Other <br /> Grout Seal Depth ft M Neat Cement(94 lb hag l5-10 gal water) ❑Sand Cement <br /> ❑Bentonite(20%solids) Z Manufacturer Spec%solids % Name sack mix!7 gal water <br /> Grout Placement Method 11Pumped [3 Free Fall 11Other ❑Specs on File ❑Specs Submitted { <br /> ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick <br /> Subm <br /> PUMP in ❑Christy Box ❑Stove Pipe <br /> Submersible IJ Turbine IJ Other HP Pump Set �{Q ft Standing Water Level —�� <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased Cl Other ft <br /> Well Diameter in Tota]Depth ft Depth to Water ft ❑Casing to be Perforated from ft to <br /> Sealing Material ❑Neat Cement(94 16 bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ft <br /> ❑Bentonite(20%solids) O Manufacturer Spec%solids % Name <br /> Placement Method ❑Pumped ❑Specs on File Cl Specs Submitted <br /> p O Free Fal] 11 Other <br /> 17 Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE Surface <br /> ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 /> MINIMU 24 OURAA CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE <br /> Vmp T DATE *%A—ZL—Q3 ,. <br /> t <br /> O NT <br /> � tTH L ISIO <br /> T7 TZ7�7 <br /> EPARTMENT USE <br /> Application Accepted By �, # 1 7 <br /> Arca Employee ID# <br /> Grout Inspection By Date <br /> ❑ SPECIAL Well Permit Jqa` <br /> Pump Inspection By Date <br /> ❑ <br /> Destruction Inspection By Date WAIVER Received <br /> COMMENTS Constructed Well Depth ft <br /> PE SC Received Check#/I Amount Permit/ <br /> Codes Info B as i Remitted Date Ipvoice# Well ID# <br /> Service Re uest# <br /> 0 - 0 5 COD 3.373 7 <br /> EHD 43-02-006 <br /> 12/6/2002 MASTER WATER WELL.PERMIT <br />