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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONME..NTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7647 FOR INSPECTIONS ECXXPPIRES I YEAR FROM DATE ISSUED JOBADIIRESS � �g� TOp)�t�O�c�i CITY/ZIP `,��C •�� g� a VV �' n Z, b CROSSSTR£ET T`��C'�`�. OAC\ ` APN � Ley ^P(ARRCCELSIZE 30 i , p OWNER NAME \^�]Q��\n10�� l� it[ 7 , PHONE OWNERADDRESS 1 O �4 SC `- CITY/STATE/Zip CONTRACTOR y 1�SJ1\V ` �... PHONE CONTRACTOR ADDRESS Va& CITY/SrATE/ZIPI::�,-\c—,-aOT,\yU\�('��+r•�•��J�� SUBCONTRACTOR 'n,'�" _- PIIONE�\ 1 11 SUBCONTRACTOR ADDRESS_ �� CITY/STATE/ZIP LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER ` EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED US£ Domestic/Private ❑Irrigation/AgricultuTal ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑ ublic WaterSwicm Irdifrereat Rom caner: ntn ysiem ame CantX1 ann or Vhooe.— r TYPEOF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Mudification O Test Hole ❑Other_ __ O Monitoring Well _ numbmorweus Cl Soil Boring(s) number orburmp ❑Geotechnical numb—Ithodnys Cl Well Destruction ❑Out-Of-Service Well O OutOF-Scrvicc Well Renewal N 0 New Pump XPump Replacement ❑Pump Repair ❑Cross-Cunnection Repair WELL.CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable'rool ❑Push Point ❑Other Proposed Well Depth_ R Excavation in diameter O Open Bottom ❑Gravel Pack/Gravel Size in diameter O Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Ccment(9416 hag/5JO gal warcr) ❑Sand Cement suck rrtix/7 gal water ❑Bentonite(20 solids) ❑Manufacturer Spec°!solids % Name ❑Specs on File O Specs Submitted Grout Placement Method ❑Pumped ❑Free Fell ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed BY ❑Driller O Pump Contractor ❑Other _ ❑Concrete Pedestal Dimensions: Width tl length_ft Thick in O Christy Box Cl Stove Pipe Pump Submersible O Turbine ❑Other_ _ lip- Q Pump Set�11R @ Standing Water Level WELL DEsTRUC`hONF ❑Open Bottom ❑Gravel Pack ❑Uncased O Other Well Diameter in Total Depth tl Depth to Water it ❑Casing to be Perforated from R to fl Sealing Material ❑Neat Cement(94 Ib Ixrg/5.10gal water) ❑Sand Cement .ruck rnix/7 gal water O Bentonite Pellets O Bentonite(200/a solids) Cl Manufacturer Spec%solids % Name ❑Specs on File O Specs Submitted Placement Method O Pumped --""❑Free Fail O Other - - ❑Complete with Mushroom Cap it below grade ❑Complete to Existing Surface Pad I 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. 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. MINIMUM 24 HOUR ADVANCE NOTI&JE REQUIRED FOR INSPECTIONS DATE �- -77 T D 1 - 044 S N OUNfY t • TAL ThIENT USE EENT / Application Accepted By U� PARTMto Area Employee ID# � r r 6j Grout Inspection By _ _ Date `/.J[�//y/�'_ ❑ SPECIAL Well Permit 1 Pump inspection Date--..L.. ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth— ft COMMENTS �/ /✓��P2U�'i��Lu /F /`tic/ �TrGi� L/L'+f/�G6 PE SC AmountChae Received Dafe Permit/ Invoicep Well)DR Codes Info Remitted ash By Service Request q F.HD 43-02-006 MASTER WAT FR WELL PERMIT 5nnm