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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D%Aip'RTMENT 304 E WEBER 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 I J C N C vl nnr, CITY/ZIP CROSS STREET !.t I- �} APN PARCEL SIZE J I G — p OWNER NAME DJCycPHONE OWNER ADDRESS 410 CITY/STATE/ZIP CONTRACTOR Ow V)e V PHONE UI CONTRACTOR ADDRESS CITY/STATE/ZIP v SUBCONTRACTOR PHONE (J SUBCONTRACTOR ADDRESS CITY/STATE/"ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y TownshipRange Section -� INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name omact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(s) numier of borings ❑Geotechnical number ofborings ❑Well Destruction >(Out-Of-Service Well ❑Out-Cif-Service Well Renewal ❑New Pump ❑Pump Replacement im2 Repair ❑Cross-Connection Repair WELL CONSTRUCTION C� Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom 13Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Staipless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement .ruck mLr/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 lb hug/5-l0 gal water) ❑Sand Cement suck 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 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. INIM 4 HOUR ADVAN NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 Sl E / TITLE DATE Z q3 4'M o .� P IV S NJ A OCES •IR N��. -NT 1 II .1iT DEPARTMENT USE ONLY Application Accepted By �rvuj ti Date '7 Z '�-3 Area Z Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ate ❑ WAIVER Received H—muctiUn Inspection By Date / �h USG Constructed Well Depth ft COMMENTS PE SC Received bee Amount Permit/ Codes Info By ash Remitted Date Service Request# Invoice# Well ID# C ty 3� i7 Ioc SM033 EHD 43-02-006 12/6/2002 _ MASTER WATER WELL PERMIT