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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L .RTMENT 304 E WEBER _3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ! Q JOB ADDRESS ,>Oo n 7 C C�Cu \S3OIA >,_\�1(tfZ - CITY'/ZIP R' CROSS STREET C�ci��smr�+r� �—�L. \ APN `253--22 6 rC!3 PARCEL SIZE OWNER NAME ��.1 \ :i r-cL` �\rte. �.,�� PIIONE OWNER ADDRESS t� CITY/STATE/ZIP K rQ C.-Y ps alS3'i�O CONTRACTOR u . c000 '*Swp E�eC;T"�C l' "s' PHONE CONTRACTOR ADDRESSRecLsleek!f G\tec_t-" \"O \'bk 1VCjCITY/STATE/ZIP \ rC)LLS/ C-PT SUBCONTRACTOR PIIONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBERjRq2)51�_ EXPIRATION DATE 6-'X- GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section n 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 Num er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) 13 Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump _,�TPump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft 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 hub/5-10 gal water) ❑Sand Cement sack 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 21 Submersible ❑Turbine ❑Other HP 1\/Z Pump Set 00 ft Standing Water Level 'SS ft 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 lb hag/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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIA�U31-24 H UR V NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SIGNED ADTITLE �urn� 7-eLI(1 DATE OT-I—ZZ-�� \ I AN S N SE IC IR N EPJT L H AL 7 n DEPARTMENT USE ONLY/ i �' Employee ID# Application Accepted By �r(/ t�i Date �&4!;� �'_.� Area � r Grout Inspection By Date 11. SPECIAL Well Permit Pump Inspection ByL�� - Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B s Remitted Service Request# 3< � e.t' 204- 1301 o3 _5 3 0 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002