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WELL / PUMP PERWEeERAVE3"" FL- STOCRTONCA� 1 202 - ( 0 4 J2 4 AL SANJOAQU14COUNTI -....vIRONMENTAL HEALTH DEPARTMENT L Y. -A'IBLE PERMIT I� CALL (209) 953-76971 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED NON-REFUND � (7Ip N f r`1 GI I I V I VVO I V ctrvl-clP S IDLI( Ib✓I Jaxwooaess Log CROSSSTREET r11N l4A' 51).e OWNER NAM E Lit PPP4Ma T c z3 owNERADDR cn'YISTATEJZIP PIIONE Fss /I .7D1 -3�4. 43ao LH/ G D!\)1iN W CONTRACTOR r/ � Jl� R. Ye f)d CITY/$TATFIZIP KID lo V15 (A 98571 CONTRACTOR ADDRESS Jl I� �1A�.. 140 -Ia7G -c?GYiZ SuacoxraAcroai VIA4 5(,� CITY/STwTFIZIP �P(RFORNP/e X SURCONTRAC3.i ,A .. - Y )') rnr-`�/,, L�/�f �/J�✓Jj/y1 Z NUMBen ENPIPAT'ION Dare LICENSE C-57 UC-61 UD-U9 ❑ Other Ran • Section YTownship. 6u— GEOGRAPIIIC.ALINPORMATION: Coordinalns X Water Quality MomentIg U Soil Sampling/Characterilaion INTENOED USE U Domestic/Private U IrrigetioolAgi icultural ❑ Indu9rial Q ' y ❑ Publ' reaterm 6'w j1u oma. omoer .n,. or oo. ora r Irefh t m r. ther TYPE OFVORK ❑ New well UReplacement Wdlror.du0 WelleAllemtion/Modiocmwn a"n,�oreotdayve UGUeOotechn- a"a'LerorbodnS: r� v ❑ Monitoring Wells) _ aumb t- Soil Borings) 1\Vhy > IWcll Destruction DOUI-Of-Service Well ❑ Om-Of-Service Well Renewal _ ❑ New Pum ❑ Pum Re lacement ❑ Pum Repair ❑ Cross-Connection Repair WELL CONSTRUCTION' ❑ Cable Tool ❑ Push Point ❑ Other Drilling Method ❑ Mud Rot ry ❑ Air Rotary Auger in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter P roposed Depth it Excavation I7 ❑ Conductor Casing mdiameter / Conductor Casing Depth J Casing Diameter _ in ThicknesOGauge/ASTM Schad ❑ Steel U Plastic U Stainless Steel U Other ❑ Sand Cement sack mtr / 7 gal water Grout Seal Depth H ❑ Neat Ccmenl f941h Aug /5-/0gul wore) ❑ Specs on File U Specs Submitted U Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % Name❑ Rcurdant / Accelerator (name) u1 Placement Method ❑ Pumped ❑ FreeFall ❑ Other U Ocher FATAL Installed By ❑ Driller U Pump Connector ❑ Christy Box ❑ Stove Pipe ❑ ConcretePedestal Dlmenstons: WidthR Length_ It ThickPum Set ft Standing Water Level tiP 0Submersible ❑ Turbine ❑ Other HP _ p 03 3 D O on Bottom 1,Q7 !, Pack Depth to Water )$Other _ i •a yrC WELLDESTRUCTION Ft De h Io WaterB ❑ Casing w be Perforated Rom _ H u _ a Well Dihmct _in TotalDepth � pt r U Bentonite Pellets Sealing Malarial eat Cement (941h hug/ 5-I Bgulrwrer) ❑ Sand Cement sack utu / "/ gal ware USpecs on File 11 Specs Submitted ❑ Be tonite (20% solids) U Manufacturer Spec % solids = % /Npin�.y}— ;rpt7 Placement Method Pumped ElFree Fall ❑ Other ( p Co�mpleteVto�ExllsUng Surface Pad ❑ Complete with Mushroom Cap 11 below grade i 1 HERE IV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAS { CURRENT ANDNA ORD 1 NANCES, STATE LAWS� AND RULES AND WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD REGULATIONS, I A AN THCERTIAT I AM IN COMPLIANCEFY THAT MY REUIRED LIVITNSALL WORKERS COMPENSATION LAWS. NIM.UM 24 HOUR ADVANCE NOTICE REQU IRED FOR INSPECTIONS - PLEASE CALL (2009) 95 3-769 7 .H {.CfJMI TITLE d F�- ILDE` sl .. P. C� �y� � DATE l =y Ol SIGNED J \ N I DEPARTMENT USE ONLY Area Employee IDN Application Accepted By Date ❑ SPECIAL ell PPTmI[ Date Grout Inspection By a ❑ WAIVER Recelved Date. 3 Pump Inspe<lion Oy Constructed Well Depth � it _ Destruction Inspection By or Dale COMMENTS 1 AM Chcekill Amount Perm Involet # Well ID# PE SC Received Remitted Data Service Re uestM Cedes Info By Cash 035110 MASTER WATER WELL PERMIT EIJD43-02-006