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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 I YEAR FROM DATE ISSUED JOB ADDRESS (7�(/(J,/`-' S CITV21P � o CROSS STREET ��'��-� APN �S3-"1 2 0- s PARCEL SIZE OWNER NAME CEJ f PHONE /�/1��' S" OWNER ADDRESS /�T CITY/STATFJZIP o��'�/ CONTRACTOR e L �S- � G / g `/PIIONEO 3�S " CONTRACTOR ADDRESS r ` CITY/STATFJZIP T�� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �"Olhef CI LICENSE ❑C-57 ❑C-61 ❑D-09 V fJ EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE mestic/Private O Irrigation/Agricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdiffaem from Owner. are` ysrem eme onram omen` one Number TYPE OF WORK ❑New Well Q Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number ofwells 0Soil Boring(s) numb``of borings ❑Geotechnical —baoflwnap ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement 2—ZPump Repair ❑Cross-Connectim 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 R Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth fl ❑Neat Cement(94 1b bag/S-l0 gal water) ❑Sand Cement suck mit/7 gal water ❑Bentonite(2(r,solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Ci Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ft Lengthft Thick in ❑Christy Box ❑Stove Pi PUMP >a6ubmersible ❑Turbine ❑Other HP Pump Set It Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other )y, Well Diameter in Total Depth ft Depth to Water Il ❑Casing to be Perforated from it to ft n Sealing Material ❑Neat Cement(94 1b bug/5-10gul water) ❑Sand Cement sack mix 17 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 Il below grade ❑Complete to Existing Surface Pad C I 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWN— UM NIM24 HOUR ADVANCE NOTIC��ffiiJJ__RE UIRED FOR INSPEC'rIONS SIGNED TITL� DATE-2 -2q 3 N T D 005 UN Ty E AL IE MENT DEPARTMENT US 7O�-5- S� Application Accepted By Date '3 �( Area '-? Employee I Dk54 g Grout Inspection By Dace ❑ SPECIAL Well Permit Pump Inspection By Date li)"(3 w�b6J ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Amount Chee Received Date permlU Invoice# Well ID# Codes Info Remitted ash B Service Re uest fi 43 �Z ,oso So•ov 1 EHD 43-02-006 MASTER WATER WELL PERMIT sn/zoo2