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'�/4 LL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART ENT 304 E WEBER AVE.)IIIIII01.-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-71,97 FOR IN5PF( I u)'ss EXPIRES I YEAR FROM DATE ISSUED y JOB ADDRESS �-�^�/ ! / f"/�DAJ/I)I'(/� �� ( / -7/� CIITrV�/ZIP (' /(1/ it'I A ��` }/ i y I 11 ' APN 1 /9-- 21ff' , I� (y CROSS STREET mD,Qf a IN Ll ..` � PARCEL NV.E OWNER NAME �C' —�� PHONE. `/6/[! OWNERADDRESS CITY/STATE/ZIP fes_ CONTRACTOR , l PHONE) 'T�^ CONTRACTOR ADDRESS n ,/\� —1 CITV/STATFJZIP�14q I� � GA I SUBCONTRACTOR r� kJf` •-� 'PHONNE�1/� ,4 SUBCONTRACTOR ADDRESS `� y _ I7�� / ( „ CITV/STATFJZIP L-;//l I LICENSE C ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE L• U GEOGRAPHICAL INFORMATION: Coordinate! X Y Township _ Range Section r NTENDED USE ❑Domestic/Private ❑irrtgalion/Agricultural 13 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IfdiRerent from Owner: wowr Sysarn Naim. Contact Nartm,or Phom Number LL TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Ilole ❑Other ❑Monitoring Well(s) nomberofwells ❑Soil Boring(s) numberofbonngs ❑Geotechnical numberofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal v -+ ❑New Pump 0 Pump Replacement 0 Pump Repair ❑Cross-Connection Repair n WELL CONSTRUCTION f- Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 7- Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Six in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It -� Well Casing Diameter —in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94 lb bag 15-/0gal water) ❑Sand Cement sock mor/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_ B Length_tt Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level it WELL DESTRUCTION ❑ n Botl m a el it ❑Uncaseo( ❑Other Well Diameter in Total Depth ._B Depth lo;W ter Il ❑Casing to be Perforated from B to It Sealing Material ❑Neat Cement(94 lb hug/5-/0gal water) Q,$end Cerack mar/7 gal water ❑Bentonite Pellets ❑Bentonite//(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method W mped ❑Free Fall ❑Other ❑Complete with Mushroom Cap B below grade plete 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M IM 2 D NCE NOTICE REQUIRED FOR ii SPECTIONS PLEASE; ALL 019)9 t-7y07 SIGNED Ile TITLE DATE v h IA-0. L OL N } n DEP,\R iM1IF.N Application Accepted By %�J•N Dale y-1 ; 0 Area Employee ID# . Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By f ' Date f, 11 WAIVER Received Destruction Inspection By �` NW Date y`I G-0 3 Constructed Well Depth f1 COMMENTS -� PE SC Received Check# Amount Date Permit/ Invoice# Well IDN Codes Info B as Remitted Service Request# b c -7y t s� 2 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002