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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH r "ARTMENT 304E WEBF' `/E Sao FL-STOCKTON CA 95202 - (269)468-3420 <br /> NON-REFUNDABLE PERMIT `/I,ALL 209 953-7697 FOR INSPECTIONS *4wLXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS o '�O {�//�JjC� nay- ed" q CIIT/Y'/ZIP <br /> CROSSSTREET r-� -Z II(! �rN' d' ^'r� �1 p� API aZwTp�e3Y/�<� PARCEL SIZE <br /> OWNER NAME �„J Y�I� Gln vla0 fir" lrhpe+l r v(tOGI q+CI PHONE I <br /> RV <br /> OWNERADDRESS _a7 , '�6G/?tib CITY/STATF/ZIP <br /> CONTRACTOR { f K e PHONEd �r <br /> CONTRACTORADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> G <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSEC-57 ❑C-61 ❑D-09 ❑Other NUMBER E%PIRATI E RO <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section `` <br /> INTENDED USE Domestic/Private ❑Irrigation/Agriculmral ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterintion C <br /> 1 <br /> ❑Public Water System <br /> Vdilferanrfrom vw... W.I.Syatern Name Cannot Name or ane um r (t <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) number of wells p Soil Boring(s) ^umber of bonnas 17 Geotechnical number of borinyn <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal C <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTI N <br /> Drilling Method Mud Rotary Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V <br /> Proposed Well Depth=� Ay <br /> ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size —_ in diameter .1 <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it T�� I <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 160 — ❑Steel Mastic ❑Stainless Steel ❑Other JQ <br /> Grout Seal 'DJepth ft ❑Neat Cement(94 1b bag/5-10g1 water) 12 Send Cement .ruck rnir/7 gal water � <br /> Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted , <br /> Grout Placement ethod umped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ It Length_ft Thick in ❑Christy Box ❑Stove Pipe <br /> Pump ❑Submersible ❑Turbine ❑Other HP Pump Set it Standing Water Level A <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(941A Aug/5-10g,1 wu(rr) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%Solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> // , MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED I�L S' VIA TITLE 1 '/O.ti DATE <br /> r w <br /> P 6LI HE LTH ER CE <br /> DEPARTMENTy$E O <br /> Application Accepted By `r """'�- Dale V ' (D'1 218 - Employee)D# 9�7� <br /> Grout Inspection B Date ez 0 SPECIAL Well Permit <br />