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IjJ= WELL 1 PUMP PERMIT 6vj>s;'�17'P -rV` 304 E WEBER AVE 3""FL STOCKTON CA 95202 - (209)468-3420 * SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i - NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS v `^'' �z'— - ., [',�`�4nnu? � -- -CITYIZIP �� a I /p C �. �I lZ-7 V— APN 0f 1 ' L/ � PARCEL SIZE CROSS STREET m OWNER NAME PHONE OWNER ADDRESS CITYISTATEIZIP CONTRACTOR ' PHONE �Z�7CITY/STATEIZIP N c CONTRACTOR ADDRESS �` � rn17p��— • PHONE SUBCONTRACTOR SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE 157 ❑'C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE G� GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangC Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring oi]Samp]inglCharacterization ❑Public Water System Contact Narne or Phone Number If different from Owner: Water ystem Name a TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other Vi number of wells number of borings number of borings ❑Soil Boring(s)s Geotechnical i ❑Monitoring Well(s) gO � C ❑Weli Destruction ❑Out-Of-Service Weil ❑Out-Of-Service Well Renewal ❑New Pum ❑Pum Replacement ❑Pum Repair ❑Cross-Connection Re air i WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Au r ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 4 7 ft Excavation to diameter ❑Open Bottom ❑Gravel Pack 1 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 k Grout Seal Depth ft ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement ruck mix 17 gal water i CIBentonite(20%solids) 0 Manufacturer Spec%solids % Name CI 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 ft Thick in ❑Christy Box ❑Stove Pipe r PUMP ❑Submersible ❑Turbine '' ❑Other HP Pump Set ft Standing Water Levei 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 f Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement suck mix 17 gal water entonite Pellet G^IF 6z%yj ❑Bentonite(20%solids) EI Manufacturer Spec%solids % Name 11 Specs on File Submftte Placement Method ❑Pumped ❑Free Fall ❑Other a ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN w+l JOAQUIN COUNTY ORDINAN ES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT D ACTIVE WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKSqMPENSA;0YAERM ]MUM 24DV CENOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091)953-7697 SIGNED `- TITLE 1#F{'�£N� ^fZ DATE 005-03.., f ` - a , txhv ia• 5 / � t K - ''� , P Y T4NV R.6E _ t. lrsoo'. - Ot aAN AOUIH COUNTY R$ MAPF W YA t l EAR '�✓ { 1 �.ri.uCwa�ACT -177 DEPARTMENT US ONLY �y Applicati6n Accepted By Date ti Area 2t Employee 1D# 4 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received �'7"Fz�/ Date Constructed Well Depth ft Beskhtrettetr inspection By COMMENTS /-;-2&ji / << y �), �s-9f6/ >� .✓ '�1��LzEs1 Nv PI/ G�.4r1� d5 PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted I Service Reg uest# 34-5 .-7 ist� �� K .6-737a53` EHD 43-02-006 MASTER WATER WELL PERMIT