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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARWELL/PUMP PERMIT <br /> NT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABL <br /> E CA L(209)9- -76 7 FOR INSPECTIONS EXPIRES 1 YE R FROM DATE ISSUED <br /> JOB ADDRESS ` JNCITY/ZIPCROSS STREET - / Sj /�/ D <br /> D( ! <br /> APN I 20"Z S PARCEL Slze H y a <br /> � <br /> � l r <br /> OWNERNAME '��y•A <br /> PHONE `l y 6 3 3 r y <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR r-1 r-1 —11, 46k." �5 ^ U , ! <br /> PHONE .GyS <br /> CONTRACTORADDRESSO- 'f[j1,� y� <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other <br /> NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Township_ Range Section <br /> INTENDED USE ❑Domestic/Private �rrigation/Agricultural ❑Industrial <br /> ❑Water Quality Monitoring _ El Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdifferem from Owner. erer <br /> ystem me <br /> Doan ame or ane um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well eChWell Alteration/Modification ❑Test Hole <br /> ❑Monitoring Well(s) numberofwells 11 Other <br /> ❑Soil Borings) numberoCbarinys number afborin <br /> ❑Well Destruction ❑Geotechnical bs <br /> O Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pu-2 ❑Pump Re lacement ❑Pum2 Repair <br /> WELL CONSTRUCTION 'Cross-Connection Re air <br /> Drilling Method D Mud Rotary ❑Air Rotary ❑Auger 8 ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter <br /> 13Open Bottom CI Gravel Pack/Gravel Size <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad <br /> Grout Seal Depth ❑Steel CI Plastic ❑Stainless Steel 13 Other <br /> ft ❑Neat Cement(94 1b hug/5-10 ul water <br /> g ) ❑Sand Cement mix/ water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec^/,solids % Name <br /> suck 7 gal <br /> _ <br /> Grout Placement Method ❑Pumped ❑Free Fall 0 Other ❑Specs on File ❑Specs Submitted <br /> ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor <br /> ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ft Length_ft Thick <br /> PUMP in 11 Christy Boz ❑Stove Pipe <br /> ❑Submersible 11 Turbine 11 Other Hp <br /> Pump Set It Standing Water Level R <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased <br /> Well Diameter_in Total Do th ❑Other <br /> P ft Depth to Water ft ❑Casing to be Perforated from ft to <br /> Sealing Material ❑Neat Cement(94 16 bug/5-10 gal water) ❑Sand Cement ft <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name sack mix/7 gal water ❑Bentonite Pellets <br /> Placement Method ❑Pumped 13 Free Fall Specs on File ❑Specs Submitted <br /> ❑Other <br /> Cl Complete with Mushroom Cap ft 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 /> CURRENT AND ACTIVE WITH Ti <br /> ii <br /> COUNTY ORDINANCES,E ST LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> IFORN[A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP ATION LAWS <br /> MINI OU ADVANCE NOTICE REQUIRED FO NSP'CT ONS—PLEASE CALL(209)953-7697 <br /> SIGNED TITLE <br /> DATE <br /> 4 <br /> N <br /> H EP <br /> DE RTMENT USE O <br /> Applicaatioti n Accepted By r` 0 <br /> / Area Employee ID# <br /> Grout Inspection By Date ��tt�� <br /> Pump Inspection By Date ❑ SPECIAL Well Permit <br /> LE �—�� <br /> —T ❑ WAIVER Received <br /> Destruction Inspection By Date <br /> COMMENTS P-A — Q Constructed Well Depth ft <br /> PE SC Recelved Check#/ Amount <br /> Code's Info B ash Remit ed Date Permit/ <br /> Service Re uest# Invoice# Well ID# <br /> d� SKoo <br /> 'POD 23-�--7 5-- <br /> EHD 43-02-006 <br /> 12/6/2002 MASTER WATER WELL PERMIT <br />