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WELL/PUMP PERAUT 2,&-1' 8 -� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AYE 3-FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CIT"ZIP Q L►(J�� r�i <br /> a <br /> CROSS STREETorC J1t- IO 4 <br /> PN_. /-I zo-Q3 PARCEL SIZE —/ LAND USE APPLICATION# p <br /> OWNER NAME /! fiO C <br /> C �' (L(r 'f 4',s PHONE <br /> OWNER ADDRESS SS4 lv. P CITY/STATE/ZIP <br /> CONTRACTOR ' r1 <br /> PHONtE� Oa <br /> CONTRACTORADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE OIC-67' 0661 ❑D-09 ❑Other NUMBER 3222UQExPiRATioN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomestic/Private ❑Irrigation/Agricultural O Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> VdifTerentfrom caner. stet stem ame onnct ame or one um t <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s)-----j of wells ❑Soil Boring(s) #ofborings O Geotechnical t1ofborings <br /> O Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> New Pump E3 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other ` <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑Other <br /> Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove P e <br /> PUMP IPLSubmersible 0 Turbine ❑Other HP•,2 Pump Set o4g[2 ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter_in Total Depth ft Depth to Water ft 13 Casing to be Perforated from ft to ft <br /> Sealing Material 13 Neat Cement(94 th hag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> 0 Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> 1 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M1IINIh M 24 HOUR ADVANCE NOTICE QEQUIR/ED FOR INSPECTIONS <br /> SIGNEDTITLE /�� DATE <br /> lilt <br /> In <br /> E <br /> T T <br /> - - "DEPARTMENT USE ONLY <br /> Application Accepted By r Date Area Employee ID# 6a`FQy <br /> Grout Inspection By Date ��j� 13 SPECIAL Well Permit <br /> Pump Inspection BZ <br /> Date_ `t — 13 WAIVER Received <br /> Destruction]nspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received 4he Amount Permit/ <br /> Date - <br /> Codes Info B Cash Remitted Service Rearrest# Invoice# Well ID# <br /> V.ko osv so.t�7 8 �L�ot f 1 a <br /> EHD 13.02.006 <br /> 12/SYt003 MASTER WATER WELL PERMIT <br />