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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 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 ✓r/✓ S ` `��-L/t) CITY/ZIP '7�7' > <br /> /f _ O <br /> CROSS STREET ''^�'V�N APN X`5 3" 1 2 O- -S PARCEL SIZE <br /> OWNER NAME 6412 1— �� // /•` PHONE 1A S/y <br /> OWNER ADDREqSS 9/ 7 / CITY/STATE/ZIP <br /> CONTRACTOR e fL r2' �G PHONE-XS�2y <br /> l <br /> CONTRACTOR ADDRESS -` l CITY/STATEIZIP <br /> loop <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS (� CITY/STATE/ZIP rX� <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 'Other G�� (/�/ NUMBER /V��� EXPIRATION DATE L r <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE mestic/Private ❑Irrigation/Agricultural O Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdifferenr from W..er y—nn ame onuct —or one um r <br /> TYPE OF WORK ❑New Well 0 Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) numberorwells p Soil Boring(s) numberofbonngs ❑Geotechnical number or borinyn <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement 21—&Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool O Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft �v <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth A ❑Neat Cement(94/h fag/S-/0 gal water) ❑Sand Cement .rack int,/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted G <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Duller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ ft Length_ft Thick in ❑Christy Bos ❑Stove Pi <br /> PUMP %.B:6ubmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level tl <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other A <br /> Well Diameter in Total Depth It Depth to Water ft ❑Casing to be Perforated from fl to ft fl <br /> Sealing Material ❑Neat Cement(94/h lag/3.10gol waver) ❑Sand Cement .sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(200/6 solids) O Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall O Other V <br /> ❑Complete with Mushroom Cap tl below grade ❑Complete to Existing Surface Pad <br /> C <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. 1 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 <br /> NIMUM 24 HOUR ADVANCE NOTIICRRE(�Q�`UIRED FOR INSPECTIONS / <br /> SIGNED TITLq/'�" DATE) -2 q �3 <br /> N <br /> T <br /> D <br /> iz <br /> 005 <br /> 01 c LINTY <br /> E U- <br /> H E <br /> MENT <br /> DEPARTMENT USF O`(VLY f <br /> Application Accepted By c fate 3 �/�--5' Area ^Z(�' Employee ID# V <br /> 99 <br /> Grout Inspection By ofDate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date&-13��lS6J ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Amount Chec Received Permit/ <br /> Codes Info Remitted ash By Date Service Request M Invoice p Well IDp <br /> 43 0- ,oSo So-00 (� Y <br /> EHD43-02-006 MASTER WAl"ER WELL PERMI"r <br /> 5/72002 <br />