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WELL /PUMP PEFUM f SAN JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3""FL-STOCKTON CA 95202 - (209)468 3420 NON-REFUNDABLE PERMIT CALL(249)953-7697 FOR 1NNPECTIONS EXPIRES I YEAR FROM DATE ISSUED cl,w r m I JOB ADDRESS f L IJ tP ti �k r s+L{s, i,�)}1 G'1 i '�]` �] CITYIZIP 1{J l Lt" `t't I____L_ CROSS STREET "ice t V, f�. n+C� APN I ! y ! PwRCEL SIZE-Oa y LANs USE APPLICaTIDN# M OWNERNAME �p w �trt't.w'L1 L C\ PHONE 1•f-� � 4i L Lei L OWNERADDRESS iiG uL.i t JI tCaf�t.! �r� CITYISTATEIZIP_ I Jf3e 'tn (T y r CONTRACTOR rt _ r'��r11i L+ )7- CF � t� r CCONTRACTOR ADDRESS 3 r'ti! I{{�,r)� 41TYISTATE/ZIP -Al(C I?N U f t f( C7 - l SUBCONTRACTOR } PHONE l SUBCONTRACTOR ADDRESS CITYISTATEIZLP LICENSE RC 57 ❑C 61 ❑D 09 11Other NUMBER EXPIRATION DATE r GEOGRAPHICAL INFORMATION Coordinates X Y Township Rang¢ Section y INTENDED USE O'bornestm/Private Q Irrigation/Agncultural ❑Industrial ❑Water Quality Monitoring 0 Sail SamplinglCharactenxaaen 'Tr ❑Public Water System IfdFrerentfram Owner Coriact N,me nr one Number TYPE OF WORK ❑New Weil ❑Replacement Well 0 Well Alteration/Modification ❑Test Hole ❑Ocher ❑Monitoring Well(s) #of wells ❑Sat1 Boring(s) R of 6annss Boring(s) ❑Geotechnical %ofbonnpp ❑Well Destruction XOut Of Service Well ❑Out Of Service Well Renewal ❑New Flamp 0 Pump Replacement ❑Pump Repair ❑Cross Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑Air Rotary 0 Auger ❑Cable Tnol ❑Push Point LI Other Proposed Well Depth ft Excavation In diameter C Open Bottom 0 Gravel Pack 1 Gravel Size 1n diameter ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter f in ThicknesslGauge/ASTM Schell 0 Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94!b bag/5 10 gal wafer) Q Sand Cement rack ma/7 gal water 11 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other 0 Retardant/Accelerator(name) PEDESTAL Installed BY ❑Dnller 0 Pump Contractor ❑Other ❑Concrete Pedestal Dimensions Wuhh ft Length ft Thick in ❑Christy Box ❑Slave Pipe PUMP ❑Submersible ❑Turbine 0 Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Weil Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from It to ft I Sealing Material ❑Neal Cement(94 lb bal,/5 10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets M Beatomtc(2096 solids) ❑Manufacturer Spec%solids 9,16 Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall i7l Other ❑Complete with Mushroom Cap ft below grade Cl COmplele 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 MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS T� SIGNED (t i.tr,.t Irl.�-`��I _ TITLE J1/+$A,i.� -i'sf Vll.35A DATE t � r r 1 I v } ( Irt I ( 3 ( 1 iKM Nmil Fix"T Ui } N l A r DEPARTMENT US ONLY Application Accepted By f Date _ Area / p y / Em to ee ID# Grout Inspection By. Date 11SPECIAL Well Permit 31% Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS I 1 PE SC Rec¢Ived /Che Amaunl Date Perm t/I r Invoice# WeIIID# Codes Info B L-C-ash� Remitted Service Quest 0() 3''/-?-7I'll X11 EHD 47 01 006 MASTER WATER WELL PERMIT 17/71/2003 I