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t r„l-T co( j • r ELL / PUMP PERMIT AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 ION-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED OB ADDRESS Lt)y CITY/ZIP y. m / O 'ROSS STREET - API PARCEL SIZE m 1WNfR NAME _7�i�l'Cc 711 ' /!� �{.CN� PHONEZ/`—�Jl<Q� $/ )WNER ADDRESS X./��.4/J/W CITY/STATE/ZIP / CGLG,. ( `4 c./ SV, 'ONTRACTOR /�/T/K P �/ PHOON/E 7/C4ACI 'ONTRACTOR ADDRESS 6/ (Y/-Tr-E S7 CITY/STATE/ZIP �iTFiV, 655-.?d/j UBCONTRACTOR S�PG� (//7 PHONE UBCONTRACEOR ADDRESS O`3i � Wqr✓` CITY/STATEIZIP !T4&L �._ ICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER z Z45� EXPIRATION DATE' �eYO GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section iTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial XWater Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from wnee Water System Name Conlact Name or Phone Number YPE OF WORK ❑New WeIIReplacement Well 13 Well Alteration/Modification 11 Test Hole ❑Other (Monitoring Well(s)` r-R mber of wells 13 Soil Boring(s) number of borings 13 number number of borinyrs ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair VELL CONSTRUCTION N grilling Method El Mud Rotary� ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth -.7 ft Excavation_ in diameter ❑Open Bottom ;*<-Gravel Pack/Gravel Size_ in diameter p - W-217— ❑Conductor Casing_in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched .7,,L rs' ❑Steel lastic ❑Stainless Steel ❑Other Grout Seal Depth ft yL�3 _ ft Neat Cement(94 Ib hag/5-10gal water) ❑Sand Cement ,sack mix/7 gal water (n ❑Bentonite(720%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted :rout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) EDESTAL Installed By VDriller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width 2—ft Length _ Thickin ❑Christy Box tove Pipe 'UMP 0 Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level YELL DESTRUCTION ❑O en Bottom ❑Gravel Pack ❑Uncased 'Other C- -- &Itr-2_ Well Diameter min Total Depth R Depth to Water ft ❑Casing to be Perforated from C' ;47t Y Sealing Material Teat Cement(94 1b bag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentom a Pellets l ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_a4a Name ❑Specs on File ❑Specs Submitted --Z Placement Method Pumped ❑Free Fall ❑Other -() omplete with Mushroom Cap�ft below grade ❑Complete to Existing Surface Pad HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS :URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL -FT r Welrj -L I I I I I I EPARTMENT I DUSE OhL Application Accepted By Date Area Employee ID#7 7 7 Grout Inspection By 4km ' Date O ACLJ?JLi ❑ SPECIAL Well Permit Pump Inspection By Date /� ❑ WAIVER Received Destruction Inspection By Dare 1c- �7 UL Ott"''— Construct d Well Depth It COMMENTS (ICf' t' 2 4 Ih DIA P- 6 W� n flf I"t7' PE SC Received Checkt!/ Amount Permit/ Invoice# Well ID# Date Service Re nest# Codes Info B Cash Remitted 3 I MASTER WATER WELL PERMIT EHD 43-02-006 12/6/2002