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WELL / PUMP PERMIT 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 344 E WEBER AVE 3""FL-STOCKTO14 CA 95292 - (209)468-3420 NON-REFUNDABLE PERMIT CALL, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JO9 ADDRESS Y T 11 G CITY/ZIP aP / CROSSSTREET t-4CC AARLArl RA. i'i/�;�'F9 Y'f VKi_ APN t1 -'GZ PARCELSIZE &, 5 IN' v OWNERAME � �� SCg + Q V LO-4o —sf�c— _ PHONE � M OWNER ADDRESS D 1Y �7c /rJP/Y/ STAT /ZIP_ COTtTRACTOR ��_r0;� �t�/rLS+ 7tr{.�CT�OI+I _ _ _ YHONE <O IO�{D'r �+aO it ex CONTRACTOR ADDRESS 5-S'79- MAPeE MES CITYISTATEIZIP- L� VCemss /VV eq ej _ r SUBCONTRACTOR ,�— tiC.t7 PHONE SUBCONTRACTOR ADDRESS Ll61j -0?-ALLC-4 gyLO� CITYiS-rAATEIZIPFke;5,4o, C116 17-97A-12 LICENSE XC-57 ❑C-61 Q D-09 ❑Other NUMBER *�7&/ 990 1 - EXPIRATION DATE 09 ,V GO• GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rarge Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring �RGSail Sampling/Characterization ❑Public Water Syltem / If different From Owner: Waier SyMern NBMC Comact Name or Phone Number 1 TYPE OF WORK ❑New Well ❑Replacement Well Q Well Alteration/Modification 11v Test Hole 11 Other 1 ❑Monitoring Well(S) number ❑Soil Boring(5) number of borings �WGcotechnica! number ofbarings ❑Well Destruction Q Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Rt vlacemeltl 11 Pump Repair ❑Grass-Connection Repair WELL CONSTRt cTtON f Drilling Method ❑Mud Rotary 0 Air Rotary Auger ❑Cable Tool ❑Push Paint 0 Other r Proposed Well Depth 1:5 ft Excavation 11a _in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ih hvg/S-10 gal wrrler) ❑Sand Cement vack mir17 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 B. ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length II Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ti I WELL,DESTRUCTION 13 Open Bottom 0 Gravel Pack ❑Uncased ❑Other Df Well Diameter]V2_in Total Depth A'- ft Depth to Water, f} ft ❑Casing to be Perforated'. ft Sealing Material ❑Neat Cement(941h hug/5-10 gal wurer) 11Sand Cement suck mix 17 gal water x4entonite.Pellets �Ciurd ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑ es S Placement Method ❑Pumped F ee Fall ❑Other O 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. MINIMUM 24 HOUR ADVANCE (NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE r DATE B4h A 1t DEPARTMENT US;r ONLY -'•sora aawxc aourro rs [ ']C - Application Accepted By Date r Area _ Employee 1D4P 3/ Grout Inspection.By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By `%T► «ate Date f / Constructed Well Depth ft COMtJtENTS -G� - 1. PE . SC Amount Check#/ Received Permit! Codes Info Remitted Cash By Date Service Rc uest# Invoic # Weil1D 4372- 15-0 a3d' 17- EH D - TFR WATER WELL PERMIT 43.02006 5/72002