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WELL / PUMP PERMIT ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ,RTMENT 304 E WEBF. 'yE 3"°FL-STOCKTON CA 9.5202 - (209)468-3420 NON-REFUNDABLE PERMIT F.�` CAL209 953-'7697 FOR INSPECTIONS EXPIRES 1 YrAR FROM DATE ISSUED JOB ADDRESS r-' F� Aj CITY/ZtP k L C Gj s E a CROSS STREET � ji APN . (�/r �C PARCEL SIZE OWNER NAME i PHONE ~ OWNER ADDRESS �� 4 -._ CITY/STATE/"ZIP CONTRACTOR - PHONE CONTRA("i'OR AUl)k>:SS 1' 1 'I'A'rE%LIP SUBCONTRACTOR PHONE \Lj SUBCONTRACTOR ADDRESS CITY/STATE/ZIP i LICENSE ❑C-57 ©C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 1 CEOCRAPIIICALINPORMATION: Coordinates X Y Township Rxnge Section yl � INTENDED USE ❑Domestic/Private 1rrigation/Agdcultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System ' If different from Owner; I water System Name ontaci ame or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Wells number of welts number of borings number oorn C7 Soil Boring(s) ❑Geotechnical bf bis s ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal f]� ❑New Pump 11 Pump Replacement ❑Pump Repair rass-Connection Repair W WELL CONSTRUCTION I Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft I 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 13 Other Grout Seal Depth ft I Q Neat Cement(941h hug/S-!0 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 .❑Frce Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By, ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other 5 Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from 1t to !1 Sealing Material ❑Neat Cement(94 1))ht{4/540gal t,vrrr) ❑Sand Cement suck mix/7 gill water CI Itcntonite Pellets ❑Bentonite(20% solids) ❑Mututitrtturr Spar%X0141N % Natuc ❑Specs on 1"ile 11Specs Submi tied Placement Method i7 Pumped 1❑t=ree Fa 11 ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 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. I MINI UM 24 O R ADVt CE NOTICE REQUIRED 7o" INSPECTIONS— PLEASE CALL(209)953--7697 _ SIGNED TITLE_- 9-e-1— DATE is E 1 I 1 ovAl dcJ IY S fy,i)A y�iL lVll, 'r J nS'is Alotl tl' ......�.. �� - DE PARI'M IF,NT IS-E() Y'_ _ ' v AAPPicilion Accepted 7ADate _ ployee II] Grout Inspection By Date ©SPECIAL Well Permit Pump Inspection By Date ,��3 ❑ WAIVER Received Destruction Inspection E D to flConstructed W Dept ft COMMENTS PESC Received eck# Amount Date Permit/ Invo ell Well tD# Codes Info Remitted Service Re nest 05-D S 5 3 I EHD43-02-006 1 MASTER WATER WELL PERMIT t_ 12/6/2002