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WELL I PUMP PERMIT <br /> $AN JoAQUHi COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95702-(2[09)48.347! <br /> ' NON-REPUNDABLE PERMIT CALL. 209 953-7697 FOR 1N.PEC'noNS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS _,/� .Q t Z {.dV l F: �5c�rrlZrr��jj I'> <br /> CROSS STREET' APN !'l efrb j&— PARCErL1 SIZE <br /> OWNER NAME ^' �IAs,/,,Yfs PHONE.��.V 5-2— <br /> . <br /> OwNERADDRESS CrfYIS`I'ATL7AP +I, <br /> CONTRACTOR yy�tt /—�� PHONE 9/,�7 V—/A <br /> C(INI'RAC7'[111 ADDRS.IUL �ljs[l /1�i�/!F S/ CITVISTATrJ7.Ir ,�a <br /> SUBCOMTRACrOR <br /> SuscoNTRACTORADDRESS CITYISrATFPLIP <br /> RACENU 0 C47 O C-61 13 D-09 0 Other NUMSKS- ExrntxrioN DATE {- <br /> GCOGRAPRICAL INFORMATION. Coordinates X Y Township J. RoagedOr Section <br /> INTENDED USE O Domestielf rivate 0 IrrigationlAgricultural 0 industrial 0 Water Quality h4,mituring '1 Ssmpling/Characterizotion <br /> O Public Water System <br /> TYPE OF WORK O New Well 0 Replacement Well . 0 Weil AltetationfModifkation O Test Hole Vbhar <br /> D Monitoring Wells) b"Or"`ib `dSoil Boring(s) 2 'A*fforbWinF O(1cokehnial of b0""P <br /> D Well Destruction O Om Of--_Service Well 0Out-of-Service Well Renewal <br /> 0 New Pump 0 Pump Replacement 13 Pump Repair 0 Cron-Connection Repair <br /> W RLL CONSTRUCTION t <br /> DrIn ag Metbod 0 Mud Rotary O Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth��ft Excavation in diameter 0 Open Bottom 0 Gravel Pack 1 Gravel Sine in diameter <br /> 0 Conductor Casing in diamew 1 Conductor Casing Depth it <br /> Well Casing Diameter_in Thieku eoXiougeIASTM Schad 0 Steel 0 Plastic 0 Stainless Steel D Other <br /> Growl Seal Depth R 0 Nat Cement(91 lh hag/5-10 gal vwoter) 0 Saad Cement sac#ads 17 gal wow <br /> 0 Bentonite(20%solids) 0 Msnurwwrer Spa%solids % Name 0 Specs on File 13 Specs Submitted <br /> Grout Placement Method (3Pumped 0 Free Pall 0 Other D Retardant 1 Aocv)cmWf(naive) <br /> PEDESTAL ligi alktd By 0 Driller 0 Pump Contractor 0 Other <br /> D Concrete Pedestal Dimensions: Width ft Le ft Thick in 0 CbrWy Boa 0 Slave <br /> PUMP G Submersible 0 Turbine 0 Other HF Pump Set it Standing Water Level R <br /> WELL.DumucrtoN 0 Open Bottom 0 Gravel Pack D Unessed 0 Other <br /> Well Diameser in Total Depth R Depth to Water R 0 Caning to be PerfmMed Pian R to It <br /> SenDRg Material O Teat Cement(94 lb&W/5-10 gal%wer) D Surd Ccmut sack artr 17 gal water D Bentonite Pcikts <br /> 0 Bentonite(20%solids) 0 Manuhmurer Spec Sri solids_% Name 0 Spas on File D Spas Subnri0d <br /> Placemeat Meibod 0 Pumped r—Fall 0 Other <br /> 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surfhee Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL-BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIPY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 14 DVANCE NOTICE REQUIRED FQR INSPECT ONS <br /> SICrIED TITLE -+ DATE <br /> 6 <br /> TN <br /> DEPARTMENT USE NLY <br /> Application Accepted By r Dale Aon Employee IDN <br /> Grout Inspection By U Date L] SPECIAL Well Permit <br /> Pump Inspection By Dale E3 WAIVER Received <br /> Destruction Inspection By Dale Conslrocted Well Depth It <br /> COMMENTS <br /> PE SC Am nt Cbeck4U Roeei Date Perraw Invoke# well]DO <br /> Codes lore Remltled Cub Service Deet 0 <br /> min <br /> EHD43-02-006 "-' �,.. ��. MASTER WATER WELL PERMIT <br /> 51712002 /� <br />