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%/'4 LL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ayr.)m41,-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 1 oil Vs Nf'1(s I io,s EXPIRES I YEAR FROM DATE ISSUED 7-60V L(1 _) �7 OI� �( r �f CITYIZIP r: III/ 2, l J' �/ / o '' 11 )' 1 nn �7 a t/`rV J APN ff'� 4 PA�RCF.1.517.E II7''I PHONE L�(.a �i e CITVISTATEIZIP T CONTRACTOR S n l ' '25—� PHONE V /�I �- c 7Ca vj CONTRACTOR ADDRESSn L ^ CITY/STATFJZIP �/ I��4(41 CA 1,/� .�♦ 'r/ ' SUBCONTRACTOR C 1c/ I!_ PHONE SUBCONTRACTOR ADDRESS `� 2- o6: /� CFTV/STATFJZIP LICENSE C ❑C-61 ❑D-09 ❑Other NUMBER `i EXPIRATION DATE L. U GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdiff..tfrom Ownec water Sysam Comm,,Nmreor ane um r 11S% TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwelis ❑Soil Boring(s) number mbminls 13 Geotechnical numberofbonngs ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION r" Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other n Proposed Well Depth 0 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Cssing in diameter / Conductor Casing Depth Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 0 ❑Neal Cement(941b hag/5-10gat water) ❑Sand Cement sack 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_ 0 Length_fl Thick in ❑Christy Box ❑Stove Pipe Pump• ❑Submersible ❑Turbine ❑Other LIP Pump Set R Standing Water Level H WELL DESTRUCTION ❑ Vot mDel gack ❑Uncasq0(' ^ ❑Other WellDiameter n Toh1� R Depth to;W ter ) 0 ❑Casing to be Perforated from IT to Il Sealing Material 13 Neat Cement(94 Ib hag/5-10 gal water) [],Sand Ceh sack mix/7 gal water ❑Bentonite Pellets e ❑Bentonite//(20%solids) 13 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method W mped ❑Free Fall ❑Other ❑Complete with Mushroom Cap it below grade QQ&plete to Existing Surface Pad I 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. M M M 2 D VINCE NOTICE REQUIRED FOR IkSPECTIONS- PLEASE ('AI,I,I209)9 i..7�W7 SIGNED TITLE DATE I 4.121t 4, l ) ' L )N'.V - P Int TT b AV 1 DP:PARfBIf:N list:O, Application Accepted By ,�-N Date 4-l's -2y Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date (� ❑ WAIVER Received Destruction Inspection By W • N�1 Date -1 �Z'0 3 Constructed Well Depth it COMMENTS r PE SC Received CheckNV Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Request It EIID 43-02-006 MASTER WATER WELL PERMIT 12/62002