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�,WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI!'aTMENT 304 E WEBER r,3°"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YE R FROMDATE ISSUED m CITY/ZIP 2 l JOB ADDRESS / ;I ;2AD2—1PARCELSIZE CROSS STREETSB/ �r APN / _ X99_a y y C, SO PHONE OWNER NAME /al CITY/STATE/ZIP OWNER ADDRESS [�` Z Q PHONE // CONTRACTOR e CITY/STATE/ZIP e CONTRACTOR ADDRESS PHONE SUBCONTRACTOR SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �L LICENSE 1366��3 C-57 ❑C-61 ❑D-09 ❑other �^D NUMBER y EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rang¢ Section n,Ya INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water, Quality Monitoring ❑Soil Samphng/Charac[eriza[lon "1 ❑Public Water Owner: 11�` If differentter Owner. Water N,sumi Name oared eme or one um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Borings) ❑Geotechnical ❑Well Destruction 0 Out-Of--Service Well ❑Out-Of-Service Well Renewal r`v ❑New Pump 0--timp Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth it 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 Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft O Neat Cement(94 Ib hag/5-10 gal water) O Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall O Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor O Other ❑Concrete Pedestal Dimensions: Width it Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible 0 Turbine ❑Other HP Pump Se[ R Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/3-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fail ❑Other ❑Complete with Mushroom Cap it 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, STA AWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE AL ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW . M M 24 NCE NOTICE REQUIRED FOR I ECTIONS—PLEASE CALL(209)953-7697 SIGNED TITLE DATE �O3 Q P p\ S \ P\ or I all _ri _ DEPARTMENT USE ONLY Application Accepted By Date 07-90-03 Area 'G�d Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date Cl WAIVER Received Destruction Inspection By Date Constructed Well Depth It COMMENTS PE SC Received eck# Amount Date Permit/ InvoiceR Well IDR Codes Info a as Remitted Service Request R EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002 - _