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r"'YELL 1 PUMP PERMIT � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DET.,...MENT 304 E WEBER(77�"FL-STOCKTON CA 95202 - (209)4688-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 VEA JOB ADDRESS /00-100 e CITY/ZIP m a �]Q ` � i PN I/7 D nt� PARCEL SIZE �� v CROSS STREET ( C� v M OWNER NAME 7 PHONE OWNER ADDRESS [/ CITY/STATEIZIP �/� CONTRACTOR PHONE 420 66i I CONTRACTOR ADDRESS_r/�° r� �� CITYISTATEIZ[P SUBCONTRACTOR PHONE V', SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE C 57 ❑'C-61 ❑D-09 ❑Other NUMBER ExP[RATION DATE to, Q GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agiicultaral ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System i If diflferem from Owner: Water System Name Contao Name.or Phone NumEer I TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Wei](s) El 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 ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other i Grout Seal Depth ft ❑Neat Cement(94 lb hag/5-10gal water) ❑Sand Cement .tack mix 17 gal 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 C3 Pump Contractor ❑Other , ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe r Pump ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ) ft en Bottom ❑Gravel Pack ❑Uncased ❑Other Well DiametP in Total Depth_ 7-0ft Depth to Water ft 13Casing to be Perforated from 7 ft to 1�D fl Sealing Materna([ ❑Neat C ment(94 lb hag/5-10 gal water) t ement sack mix 17 gal water ❑Bentonite Pellets SiBentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Meth/ods 0 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ? MI UM 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 51CN£D TITLE DATE i 1 k IR N E TANNE. K H 15EFKR 11 IT R DEPARTMENT USE O fI Application Accepted By , -- Date ' ? Area Employee 113#e141 Grout Inspection B Date ❑ SP CIa.L Well Permit Y 1 . Pump Inspection By Date ❑ WAIVER Received Destruction Inspection Date 3 Constructed Well Depth ft COMMENTS -- -_- ° ,1Nr1 �� - �$ - ��4 36 �7�ElGl�Q3�-ri� i PE SC Received Chec Amount Date Permitl Invoice# Well ID# Codes Info B Cash Remitted I Service Request# X00 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002