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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I. RTMENT 304 E WEBEI E 3"'VL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 20 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ` I �.(.'l CITY/ � ZIP LA r� C - CROSS STREET ! (tG1r APN O Q /h /r q C% [J PARCEL SIZE 04, OWNER NAME �J ale y� PHONEYT 2 SrA OWNERADDRESS D c LCI 1 CITY/STATE/ZIP /7A ,C J(5 c s-3 CONTRACTOR PHONE CONTRACTOR ADDRESS TATE/ZIP P Q SUBCONTRACTOR Pr PHONE SVI)CON'1'RAC'1'OR ADDRFsS Crrv/srn're/'l..IP I LICENSE ❑C-57 ❑C-61 CID-09 ❑Other _ NUMDER — ExrlRn'rrgry Dn'rF: GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Secllon INTENDED USE ❑Domestic/Private i'rigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System ! If different from Owner; + ater ystem nme onwm ame or el.ne Number [� TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells er of borings b ❑Soil Boring(s) num '11 Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Wel] ❑Out-OI'-Service Well Renewal ❑New Pum ❑Pum Re lacement ❑Pump Repair toss-Connection Re air WELL CONSTRUCTION l Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/GaugetASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth tt ❑Neat Cement(94 Th hug/5-10 gal water) ❑Sand Cement suck mix!7 gal water l ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fal! ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed ft ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimcnslons: Width It Length it Thick in ❑Christy Box ❑stove Pipe PUMP ❑Submersible ❑Turbine ❑Other FIP Pump Set It Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from fito Sealing Material ❑Neat Cement(941h1 hag/5-l0 gal water) ❑Sand Cement sack mix/7 gal water ElBentonite Pellets E3Bentonite(20%solids) E❑Manufacturer Spec%solids % Name 11Specs On File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other C3 Complete with Mushroom Cap fl 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 TIIA'f MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 1j MINIMUM 24 H UR. DVAN NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 953-7697' SIGNED TITLE_ �� i �� DATE I T1 !S A I FE 1 !� I p! r\ ` 10 4F i C Ufs Bl.C H AL1 151 lhi NVt 1{ I --f I .. - — --- V I I —— ————————# A 1W + DEPARTMENT-i1.E- v- Application Accepted By Date � Employee IDp 6Q Grout Inspection By I0E 4 Date 11SPE IAL Well Permit a�r� Pump Inspection By Date ❑_. WAIVER Received Destruction Insp tion 13 Datefflnstructed We Depth ft COMMENTS — ^ 00, PE illlililll!;iiiiiiiii! SC Received Check#/ Amount Per / Cods Info B Cash Remitted to Service e u st# Invoice# Well ID# p EHD 43-02-406 12/6/2002 MASTER WATER WELL PERMIT