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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°"FL-STOCKTON CA R5202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR IN'SPECTIONS EXPIRES I YEAR FROM DATE ISSUED rn {3 JOB ADDRESS bV��,M�(tu7/ Ey 110A P_ EF.0 L47HR U P RO CITYIZIP Lh 7 ISO p � � 3V y ,A Lt9 41 Au f to CROSS STitEET a I7 d 4bP 9(612 _ _ _ _ APN /fi�r No-y� PARCEL SIZE i 3 •U OWNERNAMF. Ka' a F- Ate f4aL sAw►7 C74L _ T PHONF OWNER ADDRESS 760a 5 1PLAM) 091 U[ CITY/STATE/ZIP 70'0 & L CONTRACTOR f FP6 Co qr 1w C�r r /y,/� /PHONE !'Ja- 71/6 �1 33j CONTRACTOR ADDRESS p J ( LQr(�/CLgof t � r/l{ t or. ' L[ L7f CITY/STATE/ZIP J? SFQ14t4 r C f Q C01 SUBCONTRACTOR FIONE Q ~T7%�J -'SSS3 SUBCONTRACTOR ADDRESS _ �• CttTY/STATE( tP s.7�/11�r� ]/S LICENSE JXC-57 ❑C-61 ❑D-09 ❑Other NUMBER V Q S EXPIRATION DATE��J/l GEOGRAPHICAL INFORMATION: Coordinates X V Township Ra:ige Section INTENDED USE ❑Domestic/Private ❑1rrsgation/Agricu1111ral ❑industrial ❑Water Quality Monitoring JXrSoil Sampling/Characteruation ❑Public Water System If diffeneni rrom Owner: Water System Name omacl ame E one Flumber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modilicalion ❑Test Hole ❑Other g O� number of01615 numberarbonng, umberofbonngs )(Monitoring Wells ❑Soil Boring(s) _ ❑Geotechnical n ❑Well Destruction ❑Out-Of-Service We]1 ❑Out-Of-Service Well Renewal �'- ❑New Pump ❑Pump Re IaC.ement ❑Pump Repair ❑Cross-Conner.Lion Repair WELL CONSTRUCTION Drifting Method ❑Mud Rotary ❑Air Rotary XAuger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth I J� ft Excavation— 1%__—in diameter ❑Open Bonom Gravel Pack i Gravel Size in diameter ❑Conductor Casing in diameter i Conductor Casing Depth --11 Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel aZ Plsstic ❑Stainless Steel ❑Other_ y Grout Seal Depth (3 JI&3 ft Neat Cement(941h hag/5-10 gal water) ❑Sand Cement—_ suck mrx 17 gal water ^rj Bentonite(20%solids) ❑Manufacturer Sp^c%solids °ro Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant i Accelerator(name) PEDESTAL Installed BY Driller ❑Pump Contractor ❑Other Concrete Pedestal Dimensions: Width i3 Length_ ft Thick in ❑Christy Box Aslovepipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set_ ft Standing Water Level 11 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack L Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hag/5-10 gal water) ❑Sand Cement sack 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 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. MINI UM 24 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)95.3-7697 SIGNED & TITLE �C? '/� DATE '! r � 1 - �T � r � .�... :7;F� PROPERTY r, = E DEPARTMENT US ONYV oI Application Accepted icy Date / Area�Ls� Employee ID# Grout Inspection By Date 3 -� ❑ SPECIAL Well Permit Pump]nspeatiun By Date i ❑ WAIVER Received r Destruction Inspection By Date Construct e Well epth ft COMMENTS PE SC Received Checlk# Amount Date Permit/ Invoice# Well ID# Codes Info By ash Remitted Service Request# I L21 1S2- Zak f E H D 43-02 6 MASTER WATER WELL PERMIT 12/6/2002