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(L /U gas LWELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 604dRTMENT 304 E WEBEIAaislf 3"a FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT /J�r�1 CALL(2_09)9533-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS sVZOJ � . / yl ,,� �_�'/ . CITY/ZIP a k/ CROSS STREET L�/�7,{ l � /Q All ��qL/�i /V-Si L1r�jAPN t7.3 `2/0-'oi�-, PARCELSIZE !ter � A OWNER NAME 4[��/1.1 /C C_i�"'vFjf'/' ,+ 17� /�t,�'_' /'"f r2Vr_/r— OWNER ADDRESS 7A� LIZ- �r G Z CITY/STATF/ZIP YHt ONE CONTRACTOR CONTRACTOR ADDRESS isC !�D �LimLJ/, ,`' CITY/STATF/ZIP >•a7�✓"-/V. ��I' / �.v�� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 -61 ❑D-09 ❑Other NUMBER EXPIRATION DATE—z&—,Lo S GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultumi ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System n IrdAtereat from Owner: water system Name Contact Nam or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑///Monitoring Well(s) number of wells 0Soil Boring(s) namberofborinyn ❑Geotechnical number of borings pDwell Destruction 13Out-Of-Service Well 13Out-Of Service Well Renewal /❑New Pum ❑Pum Re lacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth 11 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal DLplh 11 ❑Neut Cement(94 ib fay:/5-lagol twurt) ❑Sand Cement x,a A ao:a/7 gal water ❑Bentonite(20%solids) ❑Manutecturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ it Length it Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set 11 Standing Water Level It WELL DESTRUCTION pen Bottom ❑Gravel Pack ❑Uncased ther JC / Well Diameter„j 2 in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to R Sealing Material ❑Neat Cement(94!6 bag/5-/Oga/water) ❑Sand Cement •s�aoc/lk/,raiz/7 gal water — Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % DtgAsD— >l —2 �e b Spec;on File ❑Specs ubmit Placement Method ❑Pumped ❑Free Fall �thern'1� x W0�- - s ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad - 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIACONTRACTORSSTATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE O I E REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 SIGNED TITLE DATE Y X404140r oy L ( f 7 E N V N 0 E v -T I M 7H EAR M s 17 DEPAR MENT USI t1ONL ' Application Accepted By Date 26 L - Area .2.�� linspioyec IU# J�� Grout Inspection By. Date ❑ SPECIAL WII Permit Pump Inspection By Date ❑ WAIVER R eived Destruction Inspection Dale Constructed Well Depth I it COMMENTS L ¢ 5 ( i7 i3 n PE SC Received Chec Amount Date Permit/ Invoice# Well 1D# Codes Info By Cash Remitted Service Reguest# �.;., 2cL 3 89 250. vLI '6 T70Y3�7'! EHD43-02 M/y1/L� f /� • f i . cl rrMASTER WATER WELL<W.E�LLuPE�RMIT 1216(2002 l-'