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Z/rh^ WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH%!P!PARTMENT 304 E WEnB.r vE 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS '!/` ©� 1�< '�"'^'!l f(i— OT " 'C�— CITY/ZIP 14.r11-1-14- ,x7 2 4 2 a CROSS STREET �,/9� APN , V 1 O/ PARCEL SIZE 1 J OWNERNAME lM��/rC�liT— (/�S � PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR -JLLS,�n1Ffr`L�vf��gc.��/ A ,,r PHONE CONTRACTOR ADDRESS Z�Z7 /1/I yI� '� CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER-91�:l z SZ EXPIRATION DATE Z GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization (� ❑Public Water System V IfdiRer .lfmm Owner: water Sysiam Name C.nuctN.mol-PhoneN..br TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Aheration/Modification ❑Test Hole ❑Other f ❑Monitoring Well(s) numblr.f wells And Boring(s) �_ numbaofborings ❑Geotechnical namberofbomp ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary .Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth=ft Excavation 4 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 13Other Grout Seal Depth ft ❑Neat Cement(94 lb hag 15-10 gal water) ❑Sand Cement .tack 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 ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ R Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set 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 lb hag/5-10 gal water) O Sand Cement sack mix/7 gal water `Bentonite Pellets IF Yzz ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Sppeecs Si[ted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STA LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH TH IF IA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMP NSATION LA M M2 H N E NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(2(Pj) 53-7697 SIGNED TITLE Q�/`��N/ DATE I D R N EN AL IHEAUHL ISI DEPARTMENT USE ONLY .L � Application Accepted By V`r+ Date Area 711 � Employee ID# ally /-i1 q Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received 1 _I Destruction Inspection By Date /l O Construct d Well Depth ft CO ENTS 7"- Pil ISC Received heck#/ Amountate Permit/ Invoice# Well ID# Codes Info B s Remitted Service Re uest# I ToR 1 230 l �3JZf5 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002