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P jj��7T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D E, WELL / PUMP y ERMI 1 NON-REFUNDABLE PERMIT `r'TMENT 304 E WFBFR A E 3""FL-STOCKTON CA 95202 - (209)4W3420 CALL(209)953-7fi97 FOR I:�SPECTIO.\"ti FRR 9�j Y/ EXPIRES 1 YEAR FROM DATE ISSUED �J /!/i�]��/Y Cid � v� CITY/ZIP 7�A-AeAj �� ^ Q ,.�� r� APN //'�'—�y� -- /^��S� PARCEL SIZE ` D © L /� p PHONE 1�� CITY/STATE/ZIT'Cl J I C ! J CONTRACTOR ADDRESS PHONE� � CITY/STATE/ZIP SUBCONTRACTOR ��. SUBCONTRACTOR ADDRESS PIIONE 0 CITY'/STATE/ZIP ��_ (� LICENSE 57 N -61 ❑D-09 ❑Other 1 UMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y O Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization e-', — ❑Public Water System Ifdiffercnr from )wnce-- n�Tnu ------C'dnmci Nome or PhiincTTmlicr -- - 1 TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells numberofborings number ofbonnbs❑Soil Boring(s) ❑Geotechnical ❑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 / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hub/5-10 gal water) ❑Sand Cement .rack mix/7 gal water C) ❑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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft 3 WELL DESTRUCTION O ❑Gr Pack ❑Uncased ��11/ ❑Other Well Diamet in Total Depth _ ft Depth to Water .:.J��—ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h bub/5-10gal water) RQand Cement 0(S suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name /�� ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped X.ree Fall O ther ��'�- M��❑Complete with Mushroom Cap ��L 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, 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. N �/f24V /ADDJVANCE NOTICE REQU IRED FOR INSPECTIONS— PLEASE CALL(209)95. 7697, SIGNED �C/' Z.L'i11�_ TITLE OLC�'� DATE �. Jl i It PIIfLII; ilAl' 6 DEPARTMENT IIS• ONL n Application Accepted By Date `� �V Arca Z(6 Employee ID# �b Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By 7 Date //-- ElWAIVER Received Destruction Inspection By < Date CY Z6 o Constructed Well Dc th ft COMMENTSLik— b V (J r ZZ PE SC Received Check Amount Date Permit/ Invoice# Well ID# Codes Info By ash Remitted Service Request# 3 -1 2 4 16.7 Z.S'0 SR 0034 '2-8' :3 EIID 43-02-006 MASTER WATER WELL PFRMIT 12/6/2002