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WELL / PUMP PERMIT ,,,---7 ql& — y( 7 SAN JOAQUIN COUNTY ENVIRONMENTAL HEAI.TH DEPARTMENT 3O4,E'WEBER AVE 3"n FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPE61ONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 75 e 6), V r O CITY/ZIP M r — > CROSS STREET I� Q PAPN Irt �a a- (Z PARCEL SIZE OWNER NAME I to /[ -rl PHONE OWNER ADDRESS G -3 7 O CITY/STATEIZ[P FSKIt64j, .26 CONTRACTOR __FAY a /�PHHONE--CII - 7% - �5 3 CONTRACTOR ADDRESS rC46'4f1W E�M at�J F, 43& t 7� IC'O CITY/STATE/LIP�,?Q5Af=L J1 �, � �, SUBCONTRACTOR /i<`[ plFv , V�yAX PHON 20 -�:3` 3$3 SUBCONTRACTOR ADDRESS_rI I:2 &, McSE7 _ CITYISTTATE/ZIP 3e LICENSE 6 C-57 ❑C-61 ElD-09 ❑Other NUMBER gQ1C'5 5 I EXPIRATION DATE -1(/3//0 6 4 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rastge Section �S INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring XSoil$amp]ing/Characterization ❑Public Water System If different from Owner: Water System Name onmct Name o,Phonc Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other JX Monitoring Weil(s) _ numberofwel15 ❑Soil Boring(s) number ofborings ❑Geotechnical number or boring ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary M Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth l5 Il Excavation $ in diameter ❑Open Bottom lig Gravel Pack/Gravel Size � in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft ' Well Casing Diameter �)- in Thickness/Gauge/ASTM Sched Y(� ❑Steel A9 Plastic ❑Stainless Steel ❑Other Grout Seal Depth a Tar S 11 VNeat Cement f94 lb bag/3-10gal water) ❑Sand Cement sack mix 17 gal water 1.31 661 ABentonite(20%solids) ❑Manufacturer Spec%solids % Name � ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped A Free Fall ❑Other_ ❑Retardant/Accelerator(name) PEDESTAL Installed By Id Driller ❑Pump Contractor —❑Other Concrete Pedestal Dimensions: Width A Length tt Thick in ❑Christy Box R1Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other _ Well Diameter in Total Depth III Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/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 Mushmom Cap ft 1�clow grade ❑Complete to Existing Surface?ad I 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. 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. MINIMUM 24 H ADVANCE NOTICE REQUIRED FOR INSPPEECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE A�-G`!' 7 DATE [ Ild 115-3 PLICE WIC D�IIER^PROPER '41 mw Eff- DEPARTMENT US ONLY Application Accepted BY Date 0 Area Z Em to ee ED# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received l(� Destruction Inspection By Date Constructed ell Depth t COMMENTS i PE SC Received hecltttl Amount Date Permit/ Invoice# Well ID# Codes Info Vy/ ZI. Kz-ersv Remitted f z— DI — it 059003�' U E H D 43-02-006 MASTER WATER WELL PERMIT 12/6/2002