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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95-"1 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL )53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRG TE ISSUED <br /> �Fye5 /z I <br /> T <br /> JOB ADDRESS � � CITY/ZIP 111 [� <br /> CROSS STREET r r Y <br /> / I[h�� r v <br /> l-. � �F� u 1'�(��a AIN C1�' �5Q — �� PARCEL SIZE <br /> p r7 <br /> �')WNER NAMSPHONE <br /> OWNER ADDRESS CITY/STATE/LIP 45 / eJ C4 '100 <br /> ( N <br /> !� <br /> CONTRACTOR /��---- 1?iC'41, Pt on/e1�/ <br /> (,r(J <br /> —CONTRACTOR ADDRESS �09 5 L CITY/STATE/ZIP /r , l _3 <br /> 611 <br /> n <br /> ^SUBCONTRACTOR e PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ,rLICENSE 0<--5 7 97< <br /> ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Womestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System U <br /> Irdilferenr from Owner Wall, ysam Name ContactNam— one N.mber b, <br /> !TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification D Test Hole ❑Other <br /> ❑Monitoring Well(s) namberorwells p Soil Boring(s) nomberorbonngs p Geotechnical nnmberorbonngs <br /> ❑Well Destruction ❑Ottt-Of-Service Well ❑Ottt-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair _ <br /> WELL CONSTRUCTION <br /> Drilling Method P-I<d Rotary, ❑Air Rotary ❑Au er ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth -j 00 ft Excavation-/Tin diameter ❑Open Bottom &avel Pack/Gravel Size�,y in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (0 in Thickness/Gauge/ASTM Sched ❑Steel 42'Pfastic ❑Stan nI s Steel 11 Other <br /> Grout Seal Depth ,/00 ft ❑Neat Cement(94 1h hag/S-l0gal water) ❑Sand Cement ,90y1 .vock mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method &fumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Ci <br /> PUMP submersible O Turbine ❑Other HP Pump Sete It Standing Water Level fl <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth fl Depth to Water It ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94/h hag/5-10 ga/waler) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(200%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> O Complete with Mushroom Cap ft 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 /> MI I UM 2-0 HOUR ADVANCE NOTICE R QUII�R�ED FOR INSPECTIONS <br /> SIGNED �V" TITLE C r) DATE z3-So3 <br /> n <br /> _ v <br /> UB IC EAU H S RVI ES <br /> c71 T77 7—N <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 3 6 `� Area Z��"' Employee ID# 53 <br /> 6h <br /> Grout Inspection By ..Gm�777ii Dai6: �Q ❑ SPECIAL Well Permit <br /> Pump Inspection By Date `� � ❑ WAIVER Received / <br /> Destruction Inspection By Date Constructed Well Depth �`�O/ ft <br /> COMMENTS <br /> PE SC Amount Received Date Permit/ Invoice# Well ID# <br /> Codes Into Remitted ash By Service Request# <br /> 3 190 ZS 56 3 32 -1 <br /> _43Ko nSa s0 S 003 <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 517!2002 <br />