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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DL._..ATMENT 304 E WEBER 3"FL-STOCKTON CA 9$202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1l'/EAR FROM DATE ISSUED Ln JOB ADDRESS / �� [tiG CITY/ZIP T rn T J QC� t7 CROSS STREET q/y /R'__--_- APNS� PARCELSIZE [° OWNERNAME �(7u T��N/NJ�� e PHONE n OWNER ADDRESS �� !i✓�✓� _ CITY/STATE/ZIPAA_SQ� CONTRACTOR �� /�L PHONE �� CONTRACTOR ADDRESS / �G g� 0�0)c / y CITY/STATE/ZIP 'A SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/Z `I IPP q LICENSE ❑C-57 ❑'C-61 ❑D-09 Other,D NUMBER 7.3-j f 3 d EXPIRATION DATE O l/~a� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rangy Section' t", Y 1NTENDED'USE -Qwt+rnesticlPriVate ❑Irrigation/Agricultural ❑industrial 13 Water Quality Monitoring -❑Soil Sampling/Characterization ❑Public Water System a If different Water System Pante Contact Name or Phone Number R TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells numgsber of borinnumber of borings 13 Monitoring Well(s) Moil-Boring(s) ❑Geotechnical ❑Well Destruction r ❑Out-Of-Service Well ❑Out-Of-Service-Well Renewal 0 New Pump hMumpReplacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] 17 Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/•Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth 11 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941h hag/5-10 gal water) ❑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 ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 17 Submersible ❑Turbine knth6r 11�_ HP Pump Sete` ft Standing Water Level Pl ft 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(941h hag/5-10ga1 water) 0 Sand Cement sack mix/7 gal water ❑Bentoni te'Pel lets ❑Bentonite(200/.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 11-Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other Q Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL I;E'60NE IN ACCORDANCE WITH`'SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 COMPENSAT LAWS. _ M I M R ADVANCE NOTICE REQUIRED FOP INSP CTIONS—PLEASE.CALL(209),953--77}697 SIGNED TITLE DATE I i I s E! A�S4 N g RV1 iy � _DEP_4RTMEN_T USF OI�l.Y _ -Wiz. -- -• <_ -. —, Application Acce ted B Da(e �1�+�0/�O r �p pp p y f � Area Employee ID# Grout Inspection By Date © SPECIAL Well Permit 7 Pump Inspection By Date -,' , 0' WAIVER'Reeeived• ; Destruction Inspection By Date Constructed Weil Depth it. COMMENTS PE SC Received eck Amount Permit! . Codes Info B ash Remitted Date Service Request# Invoice# Well 1D# �pp HHD 43-02-006 MASTER WATER WELL PERMIT F 12/6!2002