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WELL / PUMP PERMIT SAN JOAQUU IN AUNTY ENVIRONMENTAL HEALTH 1RTMENT 304 E W EBE' 'E 3M1 FL-STOCKTON C®!h{02 - (209)468-3430 NON=REFUNDABLE PERMIT "W CALL 209 953--769,7} FOR INSPECTIONS �XPfI�RAES I YEAR FROM�D�A�TjE ISSUED y JOBADDRESS /02/00 W�Sr •n L"P/C O P—aA .` CITY/ZIP R/'iC t� �� / / > 0 CROSS STREET 1)AR 2A L /W/L Z.G CIV APN PARCEL SIZE gom -Z i oWNERNAME PHONE JARl�S �'ArHdG/C G,yr.(/2GH T/ S1�JS% OWNER ADDRESS CITY/STATE/ZIP / CONTRACTOR C?? p.S nN T ! O�yjf�L �' - PHONE b,I( CONTRACTOR ADDRESS / `- �1�1C 3 / �A- CITY/STATE/ZIP T.( RLOGK gS3g/ PHONE SUBCONTRACTOR SUBCONTRACTOR ADDRESS - CITY/STATE/ZIP LICENSE ❑C-$7 ❑C-61 ❑D-09 [3 Other NUMBER E%PIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ®'Soil Sampling/Characterization ❑Public Water System Ifdiffcmnt from Owner. mer yvem ame oniem oma ar one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number o(wells number of bonny number of borings O Monitoring Well(s) Q�Soil Boring(S) � ❑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 0 Mud Rotary ❑Air Rotary %Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ,pa .R Excavationin diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter r ❑Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 1h hug/5-10gal wafer) ❑Sand Cement .ruck mix/7 gel water 0 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 Pump Set tt Standing Water Level it WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other Well Diameter_in Total Depth R Depth to Water ft ❑Casing to be Perforated from R to ft Sealing Material ❑Neat Cement(94 1b bag/5-10gal wafer) ❑Sand Cement sack mix/7 gal water XBentonite Pellets ❑Bentonite(20"/o 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 I HEREBY CERTIFY THAT i 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 COMMPENSATIO LAWS. 1 NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED �l •'�YI.1^ TITLE /71411VII"- DATE 1 I "Oda - - - -- DEPARTMENTSlS- _. __ Application Accepted By Date �� Area ' _ Employee IDp Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By nq/� Date 11 WAIVER Received Destruction Inspection By / ,V7 LL.e�f� Date t/ Constructed Well Depth It COMMENTS PE SC Amount her Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Service Re nost# Ci Q 0 6 O'er 5 .0 MASTER WATER WELL PERMIT snrzo02