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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AYE 3-17r,-STOCKTON CA 9$202-(209)4611:1420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOBADURESS CrrvIZIP <br /> //- �1/1 /—' rhe <br /> CRU$$$TREET �V•T/�yli, �_�/T.IYL/! APN N /+✓ �tJ'�V/ PARCEL SIZE ��•1 <br /> OWNER NAMEYLL1LaT TL'7'L J PHONE .93 S��.Z470 r, <br /> OWNER ADDRESS 4 /yLr ��t CITYISTATTI'LIP �'K.I��L� -coI <br /> � <br /> CONTRACTOR L'Pl Ji/.tiLU� Al/LTJ• _�e,, �.// ,�' -_ PHONE <br /> CONTRACTOR ADDRESS .452t, 1 G� /T CIiVISTATFIZ[P <br /> SUBCONTRACTOR PHONE (� <br /> TOR ADDRESS CITY/STATE/ZIP�1,1,8C,ONTRAC <br /> ESE C-57 O C 6l ❑D•09 ❑Other NUMBER Z4o�'i3 E%%RATION DATE <br /> CEOGItAPHICALINFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE DomesticiPrivatc ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifaifferent tom Owner: erer bypern ame E-OMW arae or Phone Nunbar <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification 0 Test Hole ❑Other <br /> ❑Monitoring Well(s) 'umber orwNls Soil Boring(s) -- numberofborings QGeotechnical nwnber'fburicga <br /> ❑Well Destruction ❑Out-0f-Service Well ❑Out-Of-Service Well Renewal <br /> R New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUC��rII,,OrrN <br /> �u <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth �,?jQ ft Excavation in diameter ❑Open Bottom Gravel Pack!Gravel Size in diameter <br /> ❑Conductor acing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter Tin Thickness/Gauge/ASTM Schcd ..1I10, - k, ❑Swei X Plastic O Stainless Steel ❑Other <br /> Grout Seal Depth __ fl ❑Neat Cement(941A Aug/5-10 gal water) O Sand Ce Q. sock mix 17 gal water <br /> Bentonite(20a/solids) ❑Manufacturer Spec%solids % Name ❑Specs on Fife ❑Specs Submitted <br /> Grout Placement Method •Pumped ❑Free Fall ❑Other ❑Retardant 1AYcelcrator(name) <br /> PEDESTAL Installed By 11 Driller ❑Pump Contractor 0 Other <br /> O Concrete Pedestal Dimensions: Width ft Length (t Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set it Standing Water Level it <br /> WELL DLTMUCrIO.N ❑Open Bottom ❑Gravel Pack . ❑Uncaved ❑Other <br /> Well Diameter_in 'Tots[Depth R Depth to Water ft ❑Casing tube Perforated from It to It <br /> Scaling Material d Neet Cement(94/h hag/S-10go1 wafer) ,O Sand Cement sock mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(200n solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted <br /> Placement a1ethod ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap fl 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER COMPENSATION LAWS. <br /> L I�24ADVANCE E REQU RED FOR INSPEC�CTgqIONS—PLEASE CALL(209)95 -7697SIGNED TITLF. S',rLi DATF. F <br /> rY / <br /> x <br /> I <br /> I I SAti JCPClltN Ot N <br /> N T1 Aug - -" NI ION <br /> I <br /> _ DEPARTMENT J. <br /> Application Accepted By Date L G Akre Employee IDN I S/' <br /> Grout Inspection By Date SWell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date PermlU Invoice III WeI11DM <br /> Codes Info By as 1 Remitted Service Request 4 <br /> IJ 22 t) -7 <br /> 4 <br /> EHD43-02-006 MASTER WATER WELL PERMIT <br /> 12i6/2002 <br />