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YELL / PUMP PERMIT ,SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP,_ ,RENT 304 E WEBER A. FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 15 G�av hq-, V 1 rla m IOA JOB ADDRESS CITY/ZIP CROSS STREET y� / I V APN PARCEL SIZE z Eo�t OWNER NAME /y��PH�ONE�/�gy��^�(/�1� �/A�/�a 1 OWNER ADDRESS t� CITY/STATE/ZIP '59 f`Vt,1 V Di/c O J q4" n CONTRACTOR (/� s Ip,� 6t — PHONE /� CONTRACTOR ADDRESS Tufo ft I b 5 / CITY/STATE/ZIP Pa P-A q!5NP3 UBCONTRACTOR 17 I�^�c�I r1�P ll. PHONE SUBCONTRACT R A DRESS /,(�1 I�U 1 CITY/STATE/ZIP ( IJIU LX/I II/l5 W O�J2� CEN - L'`#�'C,-�I ❑D-09 Other 1.. �rl NUMBER EXPIRATION DATE Vy�� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number err Lukr- TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole they I e L 11 Monitoring Well(s) ❑Soil Boring(s) 11 Geotechnical number of wells number of borings number of borings �tJ.✓�C�C.. ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal � ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger [ICable Tool ❑Push PointOthe Proposed Well Depth tt Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement .cock mix/7 gal water --,� ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine OtherAOW---- HP Pump Set ft Standing Water Level It WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 1h hug/5-10 gal water) ❑Sand Cement .suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%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 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 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPE SATION LAWS. MINI 4 H UR 4PVANCkNOTICE REQUIRED FO IIN�S/PEC{A�TIICONS—PLEASE CALL (209J53-769j SIGNED UPIwalTITLE� j I{ Vt, J 1�� DATE A S N E j P11 H EPARTMENT USE O:'LY' Application Accepted By Date Area Employee ID# ( Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received CShSk# Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 23� -Z4- -1cc EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002