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r WELL / PUMP PERMIT SAN JOAQUjN COUNTY ENVIRONMENTAL HEALTH DErA"RTMENT 304 E WEBER r+../3 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ` tryI 1 � JOB ADDRESS 1 1 �C(X'� CITY/ZIP I�Cc+( r v t APN ��i-u 4) CROSS STREET V�,J - '-1 V' v �`-+" PARCEL SIZE C�y OWNER NAME DCS�lL I t7 j }� PHONE ✓ /l/�/�l OWNER ADDRESS _ 11'�U W �1�1��I ell/ I\ CITY/STATE/ZIP L 10 L" CONTRACTOR OW ne 1, PHONE �( J CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE 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 USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from wnec Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) \/ ❑Soil Boring(s) El Geotechnical El Well Destruction out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pimp 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 hug/5-/0 gal water) ❑Sand Cement .tuck 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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94/h bug/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete 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. 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. INI M 4 HOUR ADVAN NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 Sk TITLE DATE t J El I V IL-- I MAN, r Y S N J AL F PITC U21- DEPARTMENT USE ONLY ` ^� Application Accepted By J Date_- j Z Area Z I Employee ID# ✓ Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received fiestrvctibn Inspection By Date Constructed Well Depth ft COMMENTS —�— s •r;�i- < - <� PE SC Received (hecw Amount Date Permit/ Invoice# Well ID# �C Codes Info By ash Remitted Service Request# 1' 3�+ i 7 SM033WI EHD 43-02-006c� �/ �C G� LG�rL�/it7G�� r MASTER WATER WELL PERMIT 12/6/2002