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!//4r - Z23 C•S- S WELL/PUMP PEPMTT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3Me FL-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED � a2 Z JOB ADDRESS Cln/ZIP J r u �7� CROSS STREET /, l �L APN t/©t'�'�LI/�•�3 - PARCELSIZE OWNERNAME � ��1 2 f fits s ]22Z E,;:-,HONE [�7^�d eP OWNERADDRESS �p"/ ,'� CITY/STATE/ZIP CONTRACTOR y��{ 'I S 111J rt-� I t'I. PHONEJ CONTRACTOR ADDRESS aer�S I r CITY/STATE/ZIPdj (Y7J' r _ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATTJZIP LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER fC EXPIRATION DATE e GEOGRAPHICALINFORMATION: Coordinates X Y Township Range Sectipn• ;: INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chatacteriation' ❑Public Water System Tdim tent fmm O—r. Water System Nam ontut arae or rnane Numer , TYPE OF WORK PJew Well 13 Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ' 13 Monitoring Well(s) oum6er ofwells ❑Soil Boring(s) ^umber ofbarings 13 Geotechnical numbe p(boring ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump O Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method &444ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth a 6V ft Excavation• 17 n diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter O Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/GaugeJASTM Sched ❑Steel jO;dlastic O Stainless Steel ❑Other Grout Seal Depth e019 ft ❑Neat Cement(94 1b hag15-10 gal wafer) ❑Sand Cement sack mtr/7 gal water Bentonite(20e/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL installed By ❑Driller 113.1mp Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ft Length_ft Thick in ❑Christy Box ❑Stove Pipe _ PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth It Depth to Water ft ❑Casing to be Perforated from it to it Sealing Material ❑Neat Cement(Y4 11,bug/5-10ga1 water) ❑Sand Cement sackmix 17 gal water ❑Bentonite Pellets ❑Bentonite(201/.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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI UNI 24�/HOUR ,JJADDVVANCE NOTICE REQUIRED FOR INSP/p4CTIONS-PLEASE CALL(209)953-7697 SIGNED LCe /,(LUL�C'�IO TITLE NG�fQN DATE —2—� Pr PP. f7 2 � UN O E M 7 �3 DEPARTMENT USE 9NLY Application Accepted By Date U 4 Area 2 1 Employee ID# Grout Inspection _ Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth it COMMENTS PE SC Received cc k# Amount Date Permit/ Invoice# Well Codes Info B sh emitted Service Request# q3•(- IN zzs.0 Q3 5a0 EHD 43.02-006�-9/yfe�pg�;Z5R4- lf,�� !(^,�.1 cc kyr- �nA .r��( WATER WELL PERMIT 12/61002