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., WELL/ PUMP PERMx F A UIN COUNTY ENVIRONMENTAL H EALTH DEPARTMENT 304 E WEBER nM1 E 3"rL S T` C 'Ni2gt 9}468 3q 20 1 SAN JO Q � NON-REFUNDABLE PERMIT CALL (209)953-7697 rOR INSPFCTI0\1 EXPIRES SCI AT 'SED `t JOBADDRESs f_+(110 +V � '1i�f if l/ fV+tN�I.JCtnI2tPSlOCI(fn�4 _._ ,� `" y r, ff11 1 / 0 CROSS STREET T1� L'r APNwlrr+i c1 n rod-47S PAR4LLS77E �� Uyy • OWNER NAM1IC V 1V te' 1_PI10ONE �/� OWNER ApDR E55 CITYISTATe2EP Lf !Q 727-17T,`43,161 7 ^717T�t I't l�74 ,,,W,.,,� CONTRACTOR t.� G Y l {t]�J W ppPIEOV1E, 27-7/1�T`t3,161�1 CONTRACTOR ADDRESS 55o IZIV?y Rd _ CITYISTATEIZIP 1110 V LS � (A •q51!� SUBCONTRACTOR I lr J AV, [, j� b, &,k I' Com" 53o 04--oA7c�',�Z. SLBCONTRACTOR A DDRESS 31;0 LA IYIi"M x441\ b , t&, 5150 CITYISTATFIZIP Ct1194errYl P.(, 1`><€ z LICENSE C 57 ❑C 61 ❑D 09 ❑Other NUMUER EXPIRATION DATE GEOGRAPHICAL INFORMATION Coordinates X Y Township Range Section lhTENDED USE ❑DoMeStIClPrivate ❑irrigation/Agricultural ❑Indusinak X Water Quality Monitoring ❑Soil SamphnglCharacterizahon ❑Public Water System Ifdufereni from Owner aiex S>Dwm N.rae umacr —or Fho.,N-6.1 TYPEOF ORI. C3New Well ❑Replacement Well ❑Wel]Alteration/Modification 0 Test Hole ❑Other [I Monitoring Well(s) avmber of Wens 13 Soil Bonng(s) number arbor,nys ❑Geotechnical n91 W,orbO,.' O >Vel]Destruction ❑Out Of Service Well ❑Out Di Service Well Renewal ❑New I`um2 ❑Pump Replacement ❑Pump Repair ❑Cross Connection Repair WELL CONSTRIJCTION Drilling Method ❑MudRoa ry ❑Air Rotary Auger 13 Cable Tool ❑Push Point 17 Other Proposed Well Depth A Excavation m dramtWr ❑Open Bottom ❑Gravel Pack I Gra.el Size In diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth R Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Slee] ❑Plastic ❑S13MICSS Sae] ❑Oihu Grout Seal Depth h ❑Ntal Cement(94!h hal.1 S 10 bvl wofer) CI Sand Cement ,uck mu/7 gal water ❑Bentonite(20%solids) Cl Manu tacturer Spec/.solids_% Name Q Specs on File ❑Specs Submitted Grout Placement Method Cl Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) PEDESTAL Installed By 0 Driller ❑Pump Contractor ©Other ❑Concrete Pedestal~ Dimensions Width fl Length_A Thick ,n ❑Christy Box ❑Slove Pipe PUMP ❑Submerstble ❑Turbine ❑Other HP Pump Set R Standing WalLr Leel fl WELL DESTRUCTION ❑O en Bottom {$Gravel Pack ❑Uncased P4 Other 'si,� +.c Well Diamet in Total Depth 7.3 ft Depth to Water Ali ❑Casing to be Perforated from R o R Sealing MaterialC•at Cement(4.lh hell,S 'Ogo!liner) 13San1 Csmert sock rax 17 bal w-er ❑Bentomte Pellets ❑Be tonne(10%solids) E3 Manufacturer Spec%solids % /17p ❑Specs on File ❑SpeCS Subm,ued Placement Method Pumped 0 Free Fall a Other ❑Complete with Mushroom Cap ft below grade Q Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDINCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIrORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS N I N U N, 24 HOUR ADVANCE NOTICE RFQUIRED rOR INSPECTIONS—PLF ASE CAI L(309)953-7697 �i l��/ i ^''t�/ �r c SIGNED L TiTLEIIJ�,Yd L.IW KJr�tSf Com. 1'I7 r DATE I�''^D� PP I r DEPARTMENT USE O%LY Application Accepted By Date Area Employee IDA Grout Inspection By Date_ ❑ SPECIAL elI Permit Pump Inspection By Date ❑ WAIVER Received j Destruction Inspection By Date Constructed Well Depth_ �3 ft COMMENTS PE SC Received Check#I Amount Perm Codes Info By Cash Remitted Dale Service Re uesl# Invoice# Well!D# EHD43 01 006 MASTER WATER WELL PERMIT