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r"VELL I PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI.,...MENT 304 E WEBER k-j"b FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT j CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEA ,0;1 ��yy JOB ADDRESS V CITYIZ[P t7� a r �1I�7 'PTY a / a CROSS STREET V-! ! O�D / PARCEL SIZE OWNER NAME '` PHONE 4 OWNER ADDRESS �V CITYISTATE/ZIP / CONTRACTORlock" PHONE�7/� 6,61 CONTRACTOR ADDRESS CITYISTATWZIP 9r 0'—Ilr SUBCONTRACTOR PHONE V ] SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSEC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE P GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section 1!! NDED USE ❑Domestic/Private 13lrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization 13 Public Water Sstem If different from owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Weil Aiteration/Modification ❑Test Hole ❑Other numberofwells namberafborings numberofborings ❑Monitoring Wells) ❑Sail Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Re air ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter f ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 1:1Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hag/S-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length tt Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R WELL DESTRUCTION iment en Bottom 1:1 Gravel Pack ❑Uncased ❑Other Well DiametP in Total Depth (1 ft Depth to Water R ❑Casing to be Perforated from 0 it-to�i ft Sealing Material ❑Neat (94 lb hag/S-10 gal water) an ementsack mix/7 gal water ❑Bentonite Pellets entonite(20%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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI UM 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953(-y7,697? SIGNED TITLE DATE � r i iR N ETA H H E R A EEfHR DEPARTMENT USE O rL Application Accepted By Date 7 Area Employee ID#tr� G Grout Inspection By Date ❑ SP CE IAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection 8' t� D Date �Z—/c� D3 Constructed Well Depth ft COMMENTS d 3 az Yale, PE SC Received Chec Amount Date Permit/ idvoice# Well ID# Codes Info B Cash Remitted Service Request# 7� S �c EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002