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3; } 11 +f.c.f -it,Ai f-S c4je rion r.1 i� .. y/ 7 - WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WERER F.3" FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIO," EXPIRES i YEAR FROM DATE ISSUED i JOB ADDRESS CITYIZIP LA7 K& _ a CROSS STREET 4i6U( AUI` V —d FARCELSI2E s OwNNERNA!MLE. Ror34u ScAj Cr C PHONE OWNER ADDRESS OO CtTYISTA'rF1'1A? S&!&ZQAQ I-C4 Z`16,� CONTRACTOR PRONE ��/;•^ 7��—� � � CONTRAc-rOR ADDRESS.1? IWI [/ 7 CITYISTATE/LIP /?a$,- u/l.,-1.PC- ^4 17 0 7 46 SUBCONTRACTOR R1,44 [ r PHONE 2Q 9-7 Be.:f2 S 3 SUBCONTRAC'I'ORAwmESS�� ✓ � C17'Y'ISTATFJ'LIP AM ��145 f 3� _ LICENSE C-57 ❑C-6! ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPH[CA L INFORMATION: Coordinates X Y Township Range Section INTENDED USE ClDomestic/Private ❑IrrigationfAgricultural ❑Industrial ❑Water QuAily Monitoring O Soil Sampling/Characterization ❑Public Water System If dillexnt from caner: waley syslem a .nnface ame n:- one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alterationiivloditicatmi ❑Test 1{ole ❑Other ;WMonitoring Well(s) --I—_ numherofwells ❑Soil Boring(s) nnmberafborings 0Geotechnical number ofhn6ngs ` ❑Well Destruction ❑Out-Of-Service Well ❑Ou1-Of-Service Well Renewal ❑New Pump ❑Pump Replacement _❑Pump Repair A ❑Cross-Connr<_tion Repair t WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cabic Tool ❑Push Point ❑Other Proposed Well Depth 1� n Exca4a[ion �_in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diamcsar i CDItdl1CIOT Casing Depth _ ,St Well Casing Diameter r in Thickness/Cauge/ASTM Sched VO ❑Steel )WPlaslic Cl Stainless Steel ❑Other Grout Seal Depth d 10 3 ft ❑Neat Cement(94 lb hub!-5-10 gul wafer) ❑Sand Cement suck mix/7 gal water 3—5 r ❑Bentonite(20%solids) ❑Manufacturer Spec%solids u`% Name , ❑Specs oa Filc ❑Specs Submitted Grout Placement Method ❑Pumped Free Fall ❑Other T ❑Retardant/Accelerator(name) PEDESTAL, installed By Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions. Width IT Length ft Thick in ❑Christy Box X Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP_— Pump Sel R Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth fit Depth to Water ft ❑Casing to be Perforated from tt to ft Sealing Material ❑Neat Cement(9411)hag/5-10gal woler) ❑Sand Cement — .rack mix r 7 gal water ❑Bentoni[e Pellets ❑Ben tonite(20%solids) ❑Manufacturer Spec%solids—`% Name _ ❑Specs on File ❑Spees Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with MUShroum Cap fl 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM OUR ADVANCE NOTICE REQU[RED FOR INSPECTIONS-PLEASE CALL(209)953-7 97 SIGNED TITLE j / ) DATE �� 1 03 it L' - �� W�K�� + ' f'un, '` .. !,-- - PROPERTY' C t 4 ':9 r W �! I LY . IjI C I..I I ,l urnp ) li �.-r F! --�'~ JI I li T Ll'••••:-2 i1111 DEPAl1TMENT USE NL Application Accepted By Date Area Employee ID# Grout Inspection By Dale d3 ❑ SPECIAL Well Permit Pump Inspection By Date_ ❑ WAIVER Received 7C� Destruction Inspection By Date Constructteedd Well De th ft COMMENTS 1A.11 .40" PE SC eceived her Amount Date Permit/ Invoice Well[DO Codes Info Remitted Scryice Request tl D EHD 43.02-006 MASTER WAl'EA WELL PERMIT 12/6J2002