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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED H JOB ADDRESS 'Z, �1 S- \CP QDV Q�i( 2L9Z< CITY/ZIP T��C �afj y CROSS STREET S APN O 4-i�'o L PARCEL SIZE ��' v 7�0 OWNER NAME Sc�cM O�cQ A, Z- ) PHONE �j��`C�a� �V \-:5I OWNER ADDRESS ��3Z �a.�c..�itse Ct }��" Com't1, CITY/STATE/ZIP CONTRACTOR �.{ .(.�P/-�'. `Y 2> �J S�--/��/rY/(ri'-s 11V(` PfION �ZI'X'-�n� D.JS[i—Z��L♦� `L e CONTRACTOR ADDRESS �c3 X- �S� � ' IIT`'/ ATJT` E7LIP�--VGy -\5-5-7?, IU' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ,a � U LICENSE ❑C-57 ❑C-61 ❑D-09 Other �-- NUMBER J3 7 )..J Q EXPIRATION DATEAr GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USEDomestic/Private O irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ... ❑Public Water Syystem m Ifdif Brent from O rri ater Syme. ame omaa rime or Phone Number (� TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ") ❑Monitoring Well(s) number ofwens ❑Soil Boring(s) numberofbodogs ❑Geotechnical wmberofburings ❑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 R 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 fit ❑Neat Cement(94 lh hog/5-10gal water) ❑Sand Cement .rack 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 %0- Pump Set Z\G ti Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth 11 Depth to Water it ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb hag!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 It 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �7INIMU 4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED_ C , _ TITLE 3?QV'nV \ DATE QZ-- .�. G r _ -Lr iN E SH nA, ,^ DEPARTMENT USE ONLY Q/`/ Application Accepted By �a'� Date ©�23"4)3 Area Employee ID# C Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection B '.J�Itf�C. DateQo� d ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Request# ._ 3Pv d'j 5�-- l3 0 0 1 z3 D3 /�OD� SD EHD 43-02-006 MASTER WATER WELL PERMIT .. 5nrz002