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WELL I PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3`° FL- STOCKTON CA 95202 - 1`2091 469-3421 NUN -REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB AODRM os-CITY/ZIP CROSS STREET .(.U: PN aS/ — 3'?a—C>kPARCEL SIZE 14' 43 LAND USE APPLICATION # d c - OWNER NAME PHONE OWNERADDRESS CITYISTATE/ZIP ��lt "��yZ,g CONTRACTOR ( PHONE i CONTRACTOR ADDRESS ,& CrrY/STATEIZIP SUBCONrRACTOR PHONE SLIBC7011 TORADDRESS �CjrTY/STATEIZIP LICENSE V C-57 [IC -61 ❑ D•09 O Other NUMBER EXPLRATION DAT-7-•31—t� (I GEOGRAPHICAL INFORMATION: Coordinates X Y TownshlD Ranee Section INTENDED USE O DomeSlic/Priyale O Irrigation/Agricultural O Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization O Public Water System Irdifferent (mm Owner; rater ystem ome nuct ameor x u el tYPEUF WORK U New Well U Replacement Well O Well Alteration,'Modification ❑ Test Hole OOther O Monitoring Well(s) !1 of wells O Soil Boring(s) a of borings O Geotechnical a orborinip O Well Destruction `OJOut-ORSemice Well O Out -Of -Service Well Renewal r1 Mew Psi V. �D.• . D.., .. WELL CONSTRUCTION Received Check#/ B as Drilling Method ❑ Mud Rotary O Air Rotary O Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth fl Excavation in diameter O Open Bottom O Gravel Pack / Gravel Size in diameter O Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel O Plastic O Stainless Steel O Other Grout Seal Depth _ R O Neat Cement (94 fb bag/5-10 gal water) ❑ Sand Cement sack rnlx / 7 gal water O Bentonite (20% solids) O Manufacturer Spec % solids % Name O Specs on File O Specs Submitted Grout Placement Method ❑ Pumped O Free Fall O Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor O Other ❑ Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible O Turbine ❑ Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION O Open Bottom O Gravel Pack O Uncased O Other Well Diameter in Total Depth ft Depth to Water fl O Casing to be Perforated from R to ft Sealing Material O Neat Cement (941b hag/ 5-10 gat wafer) O Sand Cement rack mix 17 gal water O Bentonite Pellets ❑ Bentonite (20% solids) O Manufacturer Spec %solids % Name ❑ Specs on File O Specs Submitted Placement Method O Pumped O Free Fall O Other O Complete with Mushroom Cap ft below grade O Complete to Existing Surface Pad 1 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. MINIM 24 OUR ADVANCE NOTICE QUIRED FOR INSPECTIONS SIGNED TITLE I DATE Application Accepted By Grout Inspection By Pump inspection Destruction Inspection By COMMENTS 0 A t^ G f6 WENT USI O v Date - 13 17 Area � Empleyce fD# Date ❑ SPECIAL Well Permit �J Date ❑ WAIVER Received Date Conslructed Well Depth It PE SC Codes Info Received Check#/ B as Amount Date Remitted Permits Invoice# WeItID# Service R uest# 43.sz o �5-o EHD 43-02-006 It.,7.2r20a3 MASTER WATER WELL PERMIT