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WELL / PUMP PERMIT SAN.IOAQUICOU Y ENVIRONMENTAL'HEALTH DEEP MENT 304 E WEBER E 1°FL-STOCKTON CA 95202 - (209)468-3420" ' NO F AB ERMIT ALL 209 953-7697 FOR INSPECTIONS 6—eIRES l YEAR FROM DATE ISSUED l ' �^ UlC' H J0D /' ✓ crrY!GIP��Y'��r IV�-a y CIVIQSSSTREET e' APN 7 PARCEL SIZE —. `n OWNER NAME C�1 dectJ PII0NEr / OWNER ADDRESS CITYISTATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS j CITY/STATE/ZIP SUBCONTRACTOR ,t` PIIONE__ZVI SUBCONTRACTQIteAtl `�R S CITYISTATEIZIP LICENSENW❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y ' Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigaiion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: aver. ystem Name Cofflact Name or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑ �Monitoring Wells numberofwelis numberorborings numberofborin13 Soil Boring(s) 13 Getrtechnica] � ❑Well Destruction gout-Of-Service Well ❑Out-Of-Service Well Renewal .❑New Pump ❑Pump Replacement ❑Pum Re air ❑Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Paint ❑Other Proposed Welt 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/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal, Depth ft ❑Neat Cement(941h hag 15-10 gut wafer) ❑Sand Cement .yuck inix 17 gal water � ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name EI Specs On File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall . ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other fes' ❑Concrete Pedestal Dimensions: Width tt Length 11 Thick in 0 Christy Bax ❑Stove Pipe --Z PUMP ❑Submersible ❑Turbine ❑Olher HP Pump Se[ 11 Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other bq` Well Diameter iri " Total Depth tl Depth to Water ft ❑Casing to be Perlbrated from ft to ft (\� Sealing Material ❑Neat Cement(941h bag/S-10gol wafer) ❑Sand Cement sack mu'17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pytmped ❑Free Fall ❑Other 0 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. IMMUM24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED "CLOG" TITLE DATE y.. a '� L—_.l 1. - liff U ITY UB IC EAL H NSSIQN E R DEPARTMENT TJSE O LY Application Accepted By- � ��' Date——doArea r�'` Employee IDN Q � Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction ht pe tion y Date Constructed Well Depth ft COM M ENTS -� PE SC A unt Chc 1 Receive Date Permit! Invoice# Well lD# Codes Info Remitted Casit By Service Request# 7� 00 O12- S IP-010 30e1S HliD 43.02.006 MASI'Eili WA7111 WELL lICKMi'C 5/7/_002