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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL-HEALTII DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EJXPP,I,R./ES'1 YEAR FROM <br /> DATE <br /> ISSUED <br /> 7JOdADDRESS o CITYr�IP <br /> OC <br /> - a <br /> _.,CROSS SERESTnn <br /> APN t)55- 0-0 - i 2- N {�PVARCEL SILEZ7. Ju <br /> PIIOOWNER NAME /I <br /> � <br /> 1/71 <br /> OWNERADDRES)S� j/CTS 9/9 y- yyy111 oL kr) <br /> /l �/�y �+ ACITYISTATE/ZIP `'7 / ?�� (` <br /> CONTRACTOR reS 1 L?D . 7 \SI' ? C/ `.'r /L 1�r r < ,3& `3/39 �1 <br /> PHONE <br /> CONTRACTOR ADDRESS) --- fj'1 L. q(, SCA/'Pf2g jn g 1r) CITY/STATE/ZIP <br /> SUBCONTRACTOR fV! tX� PIIP/N(E_ <br /> SUBCONTRACTOR AD—D�[Rl:!NAA 0- CiTY1STAAxL/ZIP / 1 <br /> LICENSE 11C-57 16-C-61 ❑D-09 ❑Other /t/-O01 1 NUMBER • /3S- EXPIRATION DATE V • D J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Privaie ❑Irrigaiion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water Syy_�tem <br /> IrdifRrem train Ci­e, mrr yatem ame -w. amc ur Plan,N-ibr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s)__ numberof-lis ❑Soil Boring(s) -rnbwofborings ❑GeolechniCnl numberofborings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Scrvice Well Renewal <br /> New Pump ❑Pump ReplliCentent ❑Pump Repair ❑Cross-Connection Kepair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 1 <br /> Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑(irsvei Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Suhed ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 th lag/5-10ged miler) ❑Sand Cement selck mfr 17 gal water <br /> Cl Bentonite(206/6 solids) ❑Manufacturer Spec%solids % Name ❑Specson File ❑Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) - <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width _ It Length_ R Thick in O Christy Bos ❑Stove Pipe <br /> PUMP )LSubmersible ❑Turbine ❑Other_ HP Pump Set 41'0 it Standing Water Level__J;5 R <br /> WELL DESTRUCTION ❑Open Bottom O Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth 11 Daoih to Water tt ❑Casing to be Perforated from R to ft <br /> Sealing Material ❑Neat Cement(941b bag/J-!0 gal wafer) ❑Sand Cement ruck mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑COmplete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT L HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> h11N1�UM 24 O ADVA'VCE NOTICEt�RF.�QEUREU FOR INSPECTIONS <br /> SIGNED TITLE /t/ ` _ ATE <br /> L; l` <br /> N J AC UI <br /> EfWr <br /> DEPARTMENT USE �� <br /> SE ONLY <br /> Application Accepted By RA Cal _ Dale 1 -�� Area�-j FmPloyee IDN _ <br /> Grout Inspection By Date ❑ SPECIAL Well Permil <br /> Pump Inspection By--eC ..41 Date j 0::2-_ ❑ WAIVER Received <br /> Destruction Inspcction By Dare Constructed Well Depth n <br /> COMMENTS - <br /> PE I Sc Amount Chec / Received Date Permitl Invoice Well IDC <br /> Codes I Info Remitted ash By Service Re nest N <br /> EHD43-02-006 MASTER WATER WELLPERMII <br />