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SAN JOAQVEN COU YENV1RONn,IENTAL HEALTHTM1IENT �_� rO-01:1VEoC* E}"FL $TOCKTOh CA 95202- 9-3170 <br /> NON-REFUND BL$PERMIT :ALL(2Q9r'353-7697 FOR INSPECTIONS �.P]RFS I YEAR FROM DATEl SUEn <br /> JOh AbDRF_56 S, •"''r cmfz1P_, � ' D A <br /> CetlssStRr:ET All PARce '2e <br /> OlvVER.NAAtE !Jr^1 PILON611e91 <br /> OWNER AODSZESS CITV1STATFJZtP <br /> CONTRACTORy. <br /> CONTILSC`TORADDRF.SS 0 � �7 S'�f CITYISrxTVZtP <br /> SUBCONTRACTOR <br /> S[1RCOATAAL"r'OR ADOR£SS • C) d7 LJ yCrrVISTxrEJZsP 3/�•t.a1/. t-/'/ �aLn T1/^�-•^.- <br /> LeefNse -57 0 C•61 r3 U-09 ❑Other NUMHER7— ! 6xrrRAnoN DATIE [7 <br /> CEOCRAPIIECAi.1NFQRM1IATlOt1: Coordinates X Y TUwpship 1tltrI Section <br /> TarmueD USE c DwnesticlPrivate O lirigation/Agr'tcuhuml ❑Industrial >dVater Quality Monitoring ❑Soil Sampling/Chamnedzation <br /> ❑Public Water Syytem <br /> IfoirRreat tram wart- mar yamm ame —1 .nkat Ph ncN..b. <br /> TYPE OF WORK >*lew Well 13 Rop)acemwalYWe[l M Well Altera0on/MadAc&0oa ❑Test liege Cl Other <br /> �*ontloring WelXa11 ,"yj pfw[uf Sail BDrin(f(Y) nuRlbrl OflW(IRaI 00cotecimical a1Ma6cr aflMrSna3 <br /> 13 Writ Destruiliots CI Out-OFServiee Well n Ouo-OfService Well Renewal <br /> 0 Now fillp 13 Pomp Replacement 0 Pump R air Cr Cross•Connieiion Repair <br /> WELLCONSTRUCTION �,,r, <br /> .Drilling Method 0 Mud Rotary 13 Air Rotary RI"P r. d Cable Tool O Push Point ❑Other __ <br /> Proposed Well Depth_ 3�� it Excavation-,_gin diameter Q Open Bottom IRGravet Pack f Gravcl Size !*s�in diameter <br /> ❑Conductor Cuing _ in diameter I ConducmrCasingDeplh rt <br /> Well Casing Diameter &Z_in Thick=e GaugelASTM Sched :5�0 ❑Steel >lastic Q Stainless Steel ❑Other <br /> Groat seal Depth (n R )R73ew Cement{pd lb fag/5-10 kcal tTrrlrr) ❑Sand Cement rnci4 mit/7 gal waarr <br /> ❑Bentonite(20-A[soiids) CI Monufaeturxr Spec Y[solids_% Name Cl Specs on file ❑Specs Submitted <br /> Grout Placement Method i7Pu rte Fall P7 Other 171 Remrdant l Accelerator{name) <br /> vtowAf. lmtaIred By ]ri11c; 0 Pump Contractor 0 Other � <br /> )RUCanfretC Pedestal Dimensions: Width �- R Length �fl Thick in ❑Christy Box p�...ra, <br /> alove pipe <br /> Pump CI SubnursiBle Q Tuibine CI Other HP Pump Set It Standing Water Level R <br /> WEm,DwRucnois L7 Open otionm 13 Gravel Pack 0 Uncased ©Other <br /> Well Diameair in Toral.Depth R Depth to Water Ii nCasing to be Perfvfatetl tram m 11 <br /> Sealing M-IerlA 0 1 Cement(94th b(g73-gaga!p,mery 0Send Cement saekipir 17 gat water ❑BeionttePelkis <br /> - <br /> n Bentonite(2OY[solids) D Menprxmurce Spee%eufida % Name ❑Specs on Fie 0 Specs Submillcd <br /> Placement Method i7 Pumped ❑Free Fall ❑Other-._y..._ <br /> 0 Complete with Moskmom Gap A below grade 11 Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT i HAVE PREPARED TH IS.APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAWWCOUNTY ORDINANCES,STATE. AWS,AND RULES AND RECULATIONS: I ALSO CERTIFY.THAT MY REQU1R0f1 LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS:COMPENSATION LAWS. <br /> MINIMJdM 29 HOUR ADVANCE NOTICE EQ REQUIRED OR I/INSPECTIONS <br /> SttiNED TITLE /- DATE <br /> ZWv <br /> 14. <br /> Application Accepted By Date Area , Eittpbyce'160R <br /> Grout Inspection By Date 11 SPECIAL WEII Permit <br /> Pump Enspeclion B Date 173 WAIVER Received <br /> Destruction fospection ;ieDate Constructed Well De h R <br /> COMMENTS <br /> PE 5C Ama Chet Received pore Permit/ lnvukec if WcIE IDy <br /> Codes faro Real[ By Service Request H <br /> , i <br /> F,HD 43412,006 MASTER WATER WELL PERMIT ' s <br /> 517POO2 �¢ 7� <br />