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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D*aa,,iTMENT 304 E WEBEk,`.,: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 CITYIZIP /0 j. � O�-� Q �r • • 92yo y / C//]] //p O CROSSSTREET �9/C £ /Qd- APN o5, `t'-c26t%- C4 PARCEL SIZE 1� 69 — A OWNERNAME nA,� 3e�P.Q _ PH/ONE 1�9f OWNER ADDRESS �250 T/ ///L•�oG>/ � L CITY/STATE/ZIP A CONTRACTOR PHONE �/O ) Or CONTRACTOR ADDRESS CITY/STATEIZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinate' X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System _ Ifdifferent from owner: water system ame Commut Nam or Phone Number TYPE OF WORK 12 New Well 1-3ReplacementWell Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells 0Soil Boring(s) numberofburutgs ❑Geotechnical 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 / 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 hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(200/,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_ it Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submergible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from ft to R Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Spees,Sybmitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. A MIIDilA7U�rrl/1�4HI OUDV E NOTICE REQUIRED FOR INSSP�ECTIONS—PLEASE CALL �(209a)s�9r533--776,97 ,� SIGNED ry,-O ./ 2'Llii�iw TITLE ""`l-+`r-/\ DtnUM La O✓T C. The well must be repaired under permit and inspectionby the Environ Ivlslon (San Joaquin County Development Title, Section 9-1115.4(e)) as follows- /1. Install cement surface seal around the well casing to protect the well casing sufficiently and the integrity of well grout. 2. Provide sample tap-prior to pressure tank. _ Page 1 of 2 A Division of San Joaquin County Health Care Service Application Accepted By L11. --4� Date d-D Area XLE Employee Grout Impecti Date ❑ SPECIAL Well Permit Lllgq Pump Inspect n B o Date �i�/off 11 WAIVERReceived / fr�� Destruction Inspection By Date Constructed Well Depth it COM F�T E SC Received Check#/ Amount Date Permit/ Invoice W 1 Codes Info B s Remitted Service Request# 5 3 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6QG02