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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH r-^ARTMENT 304 E WEBEP 'vE 3N"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT :ALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED to JOB ADDRESS ` S- CITY/ZIP Tc-CA-C�4 �S3Z `(� rn f� Y CROSS STREET' S Q ��D L 7 o APN PARCEL SIZE F C J� ^a� m OWNER NAME Jt�l(Y)� !\7Z- � ) PHONE �� C3 \3 I y OWNER ADDRESS ,��^TZ�'/�j/G-��-�r�y :/g,�) Y Ct��'�I `C�.p�� CCII-TTY�/STATE/ZIPf>7 CONTRACTOR CONTRACTOR CONTRACTOR ADDRESSSUBCONTRACTOR PHON� II rnpy OW 1 1 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP JI�^ LICENSE ❑C-57 ❑C-61 ❑D-09 <Other NUMBER 73 733 Q EXPIRATION DATE O GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization �\ ❑Public Water System rn If different from Owner: 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 ❑Well Destruction ❑Out-Of=Service Well ❑Out-Of-Service Well Renewal \ New Pump ❑Pump Replacement ❑Pump 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 berg/5-10 gal water) ❑Sand Cement stick 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 tt Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP 10 Pump Set 7_%0 ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from tt to ft Sealing Material ❑Neat Cement(94 1b hug/5-10 gal water) ❑Sand Cement stick 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. 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. INIMU 4 UR ADVANCE NOTICE REQUIREDFORINSPECTIONS J SIGNED - TITLE 3QVy-Ny `iec-" DATE Qv r IN E ti p1 _ DEPARTMENT USE ONLY Application Accepted By Date ��%�3�� Area Employee IfD0 Grout Inspection By Date ❑ SPECIAL Well Permit / J Pump Inspection Bt t -j\.t'/-'V— �_ Dateoa d ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Amount Check#! Received Date Permit/ Invoice# WellID# Codes Info Remitted as t By Service Request# EHD43-02-006 MASTER WATER WELL PERMIT 5/7/2002