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WELL /PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dy� rll� MENT 304 E WEBER ri,-SI'OCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT ..ALL 209 953-7697 FOR INSPECTIONS Lb vPIRRS 1 YEAR FROM DATE ISSUED r LA gdl aTrzIP IJOB ADDRESS � y CROSS STREET { APN dZ +/J� PARCEL SIZE �r�� m OWNER NAME �c boy, !' PPHONEVy OWNER ADDRESS CITYISTATEIZIP�` r CONTRACTOR �,V[��I r q PHONE�2Z_1g&e C0 CONTRACTOR ADDRESS 1 1.y CITYrSTATEIZIP SUBCONTRACTOR PHONE E SUBCONTRACTOR ADDRESS F ITYISTATE/LIP ,6 LICENSE C-57 ❑C-61 ❑D-09 ❑Other SNUMB EXPIRATION DATE GEOGRAPHICAL INFORMATION'. Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Indifferent from Owner: Water Systcm Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other E3 Monitoring Well(s) number of wells ❑Soil Boring(s) number of borings ❑Geolechnical number of borings ❑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 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth tt ❑Neat Cement(94 1b hug/5-10ga1 wider) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File El Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width tt Length ft Thick in ❑Christy Box ❑Stave Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set it Standing Water Level fl WELL DESTRUCTION 00 en Bottom ❑Gravel Pack ❑Uncased Other Well Diameter Rin Tota]Depth it Depth to Water ft ❑Casing to be Perforated Itom ft to ft Scaling Material ❑Neat Cement(94 lb hug/5-10 gal waxer) ❑Sand Cement sack mix 17 gal water >:Usntonitc Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec% olids % Name ❑Specs on File ❑Specs Submitted / Placement Method ❑Pumped ee Fall Other-real ❑Complete with Mushroom Cap it below grade ❑Complete to Exi ling 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, 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 COMPENSATION LAWS. MINIMUM SIGNED 1 t (�,�ju24 HOUR ADVANCE TOT.�fCE� QI��CO[2 INSPECTIONS ,rE 4 } C , MF 'rt. I k-~ l J 1 r DEPARTMENT USE ONLY Application Accepted By Date Arca Gmploycc IDH Grout inspection Hy ` "Date'"" "" """'"*❑ "SPECtAi Well Perrni.� - T - Pump Inspection By Ay Date ❑ WAIVER Received Destruction Inspection By C 00 Date Q Conoructed Veit Depth ft COMMENTS PE SC Amount heck#! Received Date IV Permit/ Invoice# Well ID# Codes Info Remitted as t By Service Request# 3 Illy, I f 00 012 3/h�IS EH 43-02-006 MASTER WATER WELL PERMIT 5!712002