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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH brMARTMENT 304 E WEBER ...--3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS + r`CITYIZ P 4►SC(y ,�. `rl5 2- 4C W CROSS STREET l APN n'S_ T OCA--/b PARCEL SIZE y1-(LAND USE APPLICATION# z OWNER NAME VQ� �� UG �p s;`l`r l w PHONE(2-!2 t;�rJ OWNER ADDRESS ,ZL_—7 (` 1Jt,l'�� fA CITYISTATE/ZIP `aC�C3�} '{ : C157,-z r CONTRACTOR NY 4'-r.' Cr { QG11A+-4s^ IyIC__ PHONE�� A j- +^/Ilrr �J p CONTRACTOR ADDRESS �� ,� + 1_lGity+ _ CITY/STATE/ZIP t79✓� ,`}� '4cjG'E SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 []Other GI"Q NUMBER 05(7 Z-7�Z EXPIRATION DATE tll`C�Jr GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private )e Irrigation/Agricultural ❑Industrial Q Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification l7 Test Hole ❑Other ❑Monitoring Weil(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings ❑Well Destruction ❑Out-Of-Serviec Well ❑Out-Of-Service Well Renewal ❑New Pump jXPumpReplacement ❑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 ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other `1 Grout Seal Depth A ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe f PUMP ❑Submersible Turbine ❑Other HP + 5 Pump Set 1 GO ft Standing Water Level 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(94 1h bag/5-10 gat water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑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 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ''1 MI UM 24 HOR ADVANCE NOTICE REQUI INSPECTIODN 51GNE TITLE ATE S AA n V TA -777 A M DEPARTMENT USE QNLY app tcatton7 `epftid3y -- - --Dare 1 f' o Atea, .21 --Empiby'reTDT, t-Grout Inspection By Date 11 SPECIAL Well Permit Pump Inspection By Date 0 e ❑ WAIVER Received Destruction Inspection Byrz Date Constructed Well Depth ft COMMENTS PE SC Received Chec Amount Permit/ Codes Info By Cash Remitted Dale Service Request# Invoice# Well ID# END 43-02-" MASTER WATER WELL PERMIT 1212V2003