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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 F WF.BF.R Avr.3""FI.-STOCKTo%CA 95202-(209)469-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS ' c ,y a CROSS STREET O APX r+�-O f r'Oft' '-ZI PARCEL SIZE m OWNERNAMF. 'r --�'7 P d ` —2zQ C_ O WNER ADDRES"a CITYISTATP/ZI P CONTRALI OR 1 ` - PHONE ?35- ;L91r y CONTRACTOR ADDRESS �L� [ CITVlSTATrl'LIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS q CiTY1STATEIZIP ,r LICENSE ❑C-57 Q C-61 D D-09 A01he NUMBER EXPIRATIONQAT1, GEOGRAPHICAL INFORMATION: Coordinates X Y Township Raagc Section rN-ENDEDUSE ;C?Mnestic/Private D lrrigationiAgricultural D Industrial Q Water Quality Monitoring d Soil Sampling/Characterization D Public Water System _ If diff—from Owner Water Sym..arra E-miul " nr cr TYPE OF WORK ❑New Wel! ❑Replacement Well M Well Alteradon/Moditicauon D Test Hole D Other __ ❑Monaoring Well(s) _ numocr of waas ❑Soil Boring(s) -mberorbormp 0Geotcclinieal namberofta,&0 ❑Well Destruction D Out-OFService Well ❑Out-01'-Service Well Renewal ❑New Pump D Pump Repiaeement D Pump Repair 'rase-Cunneclion Repair WELL CONSTRUCTION Drilling Method D Mud Rotary D Air Rotary ❑Auger D Cable Tool O Push Potnl O Other Proposed Well Depth__ it Excavation in diameter O Open Haltom ❑Gravel Pack/Gravel Size in diameter t D Conductor Casing In diameter ! Conductor Casing Depth 11 w Well Casing Diameter_in Thickness'GaugWASTIM Sched ❑Steel D Plastic ❑Stainless Steel ❑Other 1 W Grout Seal Depth It D Neat Cement(94 1h hag/S-10gal water) D Sand Cement .Tack mix 17 gal water 1.1 ❑Bentonite(20%solids) D Manuluaurer Spoc%solids_% Name_ ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped D Free Fall ❑Other D Retardant/Accelerator(name) PEDESTAL Installed By D Driller D Pump Contractor D Other ">- D Concrete Pedestal Dimensions: Width 9 Length rt Thick in ❑Christy Box D Stove Pipe PUMP �'ubmersible D Turoine D Other HP—/� Pump Srt ti Standing Water Level fl t WELL DESTRUCTION D Oper.Bottom 13 Gravel Pack D Lncased O Other Well Diameter in Total Depth H Dcprh to Water R ❑Casing to be Perforated from R to R Sealing Material D Neat Cement(94 1h bag/3-10gal water) O Sand Cement xack mix/1 gul water O Bentonite Pellets ❑Bentonite(201/6 solids) D Manufacturer Spec%solids__% Name ❑Specs on File D Specs Subrmued Plaeemeni Method D Pumped O Free Fall Cl Orhet ❑Complete with Mushroom Cap_._ ll below grade D Complete to Existing Surface Pad 1 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 CIiRRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Rr U UR ADVANCE NOTICE REQUIRED FOR IN PECTIONS—PLEASE CALL(209)953-7697 _ SICISEn l TIME f t r j JO.O IN VI Ilk DEPARTMENT USE N Y �: Arca •.Z (D Em to eeIDN �S(' Applic on Accepted By _ Datc p Y sCi Grout Inspection By Date ❑ SPECIAL Well Permit Pump InsM.•tion By 4v /"a'L'�— Date '�Z B _ ❑ WAIVER Received Destruction Inspection By Date _ Constructed Well Depth B COMMENTS PE SC Received Ch Ainount Permit/ Codes Info By ash Remitted Date Service A uest N Invoice0i Well TTA! 4> C (37P EHD 43-02-006 MASTER WATER WELL Pr:RM1T 12/6/2002