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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT 304E WEBkM<VE3R"FL-STOCKTON CA 95202 . (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA Z / JOB ADDRESS ilyL fS- AVcr- CITY/ZIP a /f (�. ( pr e CROSS STREET ��` APN ' (CJ T) Itw I os PARCEL SIZE tl 7 ,A1 OWNERNAME N-ry OF 644- PHONE OWNER ADDRESS /,. G �t n CITY/STATE/ZIP CONTRACTOR IZ /i r'�i"'J".2— PHONE 13Y7J �/ L` W a I 9 CONTRACTOR ADDRESS �O '!� , / YI�_— CITY/STATE/ZIP /77,.�1t� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑C-6I ❑D-09 ❑Other NUMBER [/O T Z5 L EXPIRATION DATE / GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterintion N 0 Public Water System t1 Vdifferent from Owner: Water System Name Contact Nam or Phone Number 1 TYPE OF WORK 0 New Well 0 Replacement Well 0 Well/Alteration/Modificati 0 Test Hole 0 Other ` O Monitoring Well(s) numbfq Serofwella oil Boring(s) numlxrofbono, 0Geoteehnical numberofboringi; 0 Well Destruction 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal µ ❑New Pump 0 Pump Replacement 0 Pump Repair 0 Cross-Connection Repair 1 WELL CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary 91Auger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth 72_it Excavation—_in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sin in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel ❑Other Grout Seal Depth ft O Neat Cement(94/b hag/5-10 gal water) 0 Sand Cement .tack mix/7 gal water 0 Bentonite(20%solids) 0 Manufacturer Spec%solids_% Name 0 Specs on File 0 Specs Submitted Grout Placement Method 0 Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal Dimensions: Width_ ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set It Standing Water Level ti WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Diameter in Total Depth ft Depth to Water ft 0 Casing to be Perforated from ft to It Sealing Materla1 0 Neat Cement(94 Ib bag/S-/0ga1 wafer) 0 Sand Cement sack mix/7 gal water gBentornt,Pellets 1I- CV TV I lyl GumAfbf low- C3 Bentonite(20"/solids) 0 Manufacturer Spec%solids_% Name 0 Specs on File 0 Specs Submitted Placement Method 0 Pumped 0 Fra Fall 0 Other 0 Complete with Mushroom Cap ft below grade 0 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 IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS TION LAW MINIM A E OTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-76)7 SIGNED TITLE DATE ' law 2 t1 Ti 1 'nl IIZY �Illl�l�y W.. �. N ttY. 4 tA. b �f �a a10 Nall IV "I • o;� 1 tli x-71 Aly1,pr•+-r ft7°I A1. C.A CIIHP •7i nom' y N O 7y M , N T ♦'— Q (` c DEPARTMENT USE ONLY s� Application Accepted By ` -C r Date Ab V filo UZ Area Employee ID# ///J 37V 7 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Insp Airm By - Date O? Constructed Well Depth It COMMENTS � ri PE SC Received Chec / Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# 150 Z./ 19a go Il 0-3 00 359540 EHD 43.02-006 ��s(�� 12/62002 MASTER WATER WELL PERMIT �� !/