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WELL/ MP PERMIT <br /> SAN JOAQUIN.COVATY ENVIRONMCNO Al.HEALTH DEPARTMENT 104 E WEBER AVE Y"Fi.-Star KioN CA 9$202 )40-3420 <br /> NON-REFUNDABLE PERMIT ALL 209)9.. 697 POR INSPECTIONS EXPIRES 1 YEAR FROM D SUED <br /> JOB ADDRESS �+`� C�( - `�- CITY/ZIP •' l`1hF/ ( /1S� s <br /> CROSS STREETS// ,6k,G r <br /> OWNERNAME <br /> Ilea <br /> OWNERADDRESS fV�/R,. "7 CITV/STATFJZIP Z ��!!2 <br /> CONTRACTOR 7Xg <br /> CONTRAcTORADORESs e;LrC 7— 5r CITY/STATE/ZIP �1L>Y /! <br /> SUBCONTRACTOR /& ` t ' f1 PIIONdg1e- ��_: `,IeO <br /> SUBCONTRACTOR ADDRESS -90`�f-�C do JJ�CT'/STATFJZIP�• /—Wcw ( '/ ���T�` , ^ •v <br /> LICENSE -57 00-61 0D-09 ❑Other NUMBER/.L�pe EXP'IRAQTION DATE v y ) �k2r1 V <br /> GEOGRAPHICAL INFORMATION: C...dloates X Y Townahip, RengefvN I Skc00IwC <br /> INTENDED USE ❑Domastic/Pdvate ❑IrdgatmoiAgdculluml p Industrial X"ater Quality Monitoring ❑Soil Sampling/Cham NTUtion <br /> p Public Water Syseem <br /> nuffY.m Trom Owner. .ur Syria.Nam C.n.,, .moor Pin.. Nam., <br /> TYPE OF WORK ❑New Well El Replacement Well p Well Alteration/Modification ❑Test Hole p Other <br /> `Monitoring Well(s)� "°"'be orwdb p Soil Boring(s) norniaoroormye p Geotechnical ^.mberofbonnyn <br /> 13 Well Destmdien OOut-Of-Service Well ❑Out-Or-Service Well Renewal <br /> 13 New Pump ❑Pump Re lacemcnt 13 Pump Repair 0 Crass-Connection Repair so <br /> WELL CONSTRUCHON <br /> Drilling Method p Mud Rotary p Air Rotaryager ❑Cable Tool ❑Push Paint p Other <br /> Proposed Well Depth_3 C7 ft Escavaeion in diameter ❑Open Bottom /ArGmvcl Pack/Gravel Size 2sin diameter m <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter ;2_ in Thickness/Gauge/ASTM Schad -/C7 ❑Steel XPI.sli, EI Stainless Steel p Other <br /> Grout Seal Depth_ Q it "Feat Cemcm(94 IS hag/540gu/un/er) ❑Sand Ccment .rack mcc/7 gal water <br /> ❑Bemonite(20%solids) ❑Manufacturer Spa%solids_% Name OSpmson File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped >Wrca Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By -QDnller 13 Plan Contractor 13 Other <br /> "fib' th onerete Pedestal Dimensions: Widft Length ft Thick_ _in ❑Christy Bos ystov.pl, <br /> Pump ❑Submersible ❑Turbine 13 Other HP Pump Set_R Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneaaed 13 Other <br /> Well Diameter_in Total Depth R Depth m Water it ❑Casing to be Perforated from_R to Il <br /> Scaling Material ❑Neat Cement(94 lh hay/540 go/water) OSand Cement .mckmis/7 gal water p Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name C3 Soma on File ❑Specs Submllled <br /> Placement Method ❑Pumped ❑Face Fall ❑Other <br /> ❑Complete with Mushraom Cap It below grade 0 Cmmplele tar Insist.,Surl'mc 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS.. <br /> MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> c <br /> SIGNED TITLE Sr I�iTT—K�/ DATE 1 <br /> T <br /> O <br /> 0 J <br /> ...ys� DEPARTMENT USE ONLY <br /> Application Accepted By. /' 1` Date Q Area . Employee ID4 <br /> Grout Inspection By. Date Q ❑ SPECIAL Well Permit <br /> Pump Inspection By Dam ❑ WAIVERReceived Lq L�1S <br /> Date Co strutted W 11 Depth 1 0 ! B <br /> Destruction Ins action By qq P '�- <br /> COMMENTS �Nlk)(if0. f'cSS (�„ yyo12 IQd <br /> PE SC Received Checkp/ Amount Dele P.mdv Invoiceq Well ID# <br /> Codes Info B Cash RemlHed Service Request# <br /> Trot ' 4 11411140 <br /> it <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br />