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WELL/ YUNIYPLRMI'l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-Sl'OCK'ION CA 95202 -(2U9)46&7420 <br /> P NON-REFUNDABLE PERMIT CAUL 209 951-7097 FOR IN\PE("IIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDREa$ �"'-f /'�� A y ( UV 1-L F C�.I'V/ZIP f � /J S Y <br /> CROSSSTREEI' APN /'/fYf11�11�.� PARCELSV.E O <br /> G,VNER NAME ' •(��''// /PRD.�N-,Y <br /> OWNERADDRESSC� ` CITY/STATFJZIP�J(yY' 6j�[,,�r)esy TJ <br /> CONTRACTOR y�y'Lk4&, }-, c� PHONE / l V C('/ <br /> COMIRACIORAIIIIRERR �/.lo(y/.l//y/-/l J� CITYRIAT'WZIP <br /> SUBCON'rlucruR �JI IYIONE: <br /> SUBCONI'RACTORADDRESS Cr'v/SrAT'F7ZIP <br /> LICENSE OC-57 OC-61 ❑D-09 ❑Other rvumM:x EKPIKA'MDN DA'I K +� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section -C <br /> ItTENDED UsE ❑Domestic/Pdvsta O IrrigalknVAgricultural ❑Industrial ❑Water Quality Monitoring 'Soil Snmpling/Chnneterinlin. <br /> O Public Water syysam <br /> te <br /> Ifelirtaemrmm OwnwWaer.,.Onlotme onlrci nneor vm un r <br /> TYPEOF WORK O New Well ❑Replacement Well . ❑Well AlteratioNModilication ❑Testicle 'Puller f'vt✓LLy,n.p/� <br /> numavurwdls nuMnvorbonnry - ield of punn <br /> ❑Monitoring Wella) Vo --Iv—Baring(a)- ❑G,mlahnicul w <br /> 13 Well Destruction 110 m-Of-Service Well ❑Oul-OfService Well Renewal <br /> O New Pum ❑Pump Replacement O Pump Repair ❑Cross-Connectioo Repair <br /> WELLCONSTRUCr'ION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 13 Auger (3 Cable Tool 13 Push Paint ❑Other <br /> Proposed Well Depth 6 A Excavation in diameter E3 Open Bottom Cl Gravel Puck/Gravel Siff in diameter <br /> O Conductor Casing_m diameter / Conductor Casing Depth Il <br /> Well Casing Diameter_in Thicknesa(houge/ASTM Schad ❑Steel O Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Nem Cement(94/A Aug/5-10 god wafer) E3 Send Cement wrckmlx/7 Sal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name LI Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fell ❑Other ❑Retardant/Accclemtor(name) <br /> PEDESTAL Installed By 0Driller ❑Pump Contractor ❑Other <br /> O Concrete Pedestal Dimensions: Width_ 0 Length R Thick in ❑Christy Box O Steve Pipe <br /> PUMP OSubmenible ❑Turbine [3 Other HP_ Pump Set—It Standing Water level I7 <br /> WELL DESTRUCTION ❑Open Bottom OGmvel Peck E3 Uncalled ❑Other <br /> Well Diameter in Total Depth I7 Depth to Water It Cl Casing to be Perforated Bonn_R to_B <br /> Sealing Material )West Cement(P41b bag/5-10 gra/wafer) ❑Sand Cement suek,.&/7 gales ler ❑Demerit.Pellets <br /> ❑Denverite(20X,solids) ❑Manu factumt Spee%solids_% Name ❑Specson File OSpecs Submitted <br /> Placement Method ❑Pumped )"Tree Fall ❑Other <br /> O Complete with Mushroom Cap it below grade O Complete to Existing Surface Ped <br /> 1 HEREBY CERTIFY THAT I 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 CERTIFY THAT MY REQUIRED 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 /> MINIMUM 24HOUR-ADVANCE NO'T'ICE REQUIRE I11Y)R INSI'p:("1' ONS <br /> SIGNED TITLE -a'( DATE <br /> B NJ <br /> lif <br /> HE ilii <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 13 Arae Employee IDN <br /> Grout Inspection By Dete ❑ SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER Received - <br /> Destruction Inspection By Dale Constructed Well Depth R <br /> COMMENTS <br /> PE SC Amount CheckR/ Receive Data Permit/ Invoke We111Dq <br /> .yCod. Info Remitted Cash Service Re uestp <br /> 3 G <br /> EH34I-0I-006 �N • MASTER WAI'F.R WELL PERMIT <br /> snrzooz 1111 <br />