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TTGLLI rVIVAr r1•r11,IT111 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM ENT 304EWEEERAvE3"'FI.-St'(ICKTONCA95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INS EC"1'111NS EXPIRES I YEAR FROM DATE ISSUED <br /> S �J`1 j N <br /> JOB ADDRESS 6/ 5D G. �J Vie- CII IZIPI f 'lJ �r��� �le <br /> > <br /> CROSSSTREET �y//G�r. ` APN PARCEL SIZE as <br /> OWNER NAME / U.r�4 nTV1 PLIRr `k)tizLI-A/l A�AcP-,r� PPRONE`^ey—Zjr��y.Er- } <br /> OWNERADDRESS -LA//er/ // �JaX I� CITY/SI'ATFJZIP <br /> cow CTOR Z---L YTi�AGCF'/' 7.>,C- <br /> cow PPHONE����`1�1��I <br /> CON'I'RACI'ORADDREss aPP'J 4F 1 hreneiz- 577 CITY/S'EATEILIP <br /> SUBmMrxACIOR //Ig— 1'11ONE <br /> SUBCONTRACTOR ADDRESS CITY/SIATFILIP <br /> LICENSE OC-57 0C-61 0D-09 ❑Other NUMBER_ EZPIRArIONDA'IE <br /> GEOGRAPHICALINFORMa'ATION: Coordinates $ Y Township / Itangej-/`�Seelluncs�jr <br /> INTENDED USE ❑DODIMmlc/PIN le ❑IrrigationlAgriculmml O Industrial ❑Water Quality Monitoring Soil Sampling/Chmactednlion <br /> Cl Public Water S Stem <br /> Irmrtenvonue�iwner. Vomotilue.Nam Cruise.Nunnw nw N-1wr <br /> TYPE OF WORK ❑New Well O Replacement Well ❑Well AlmmtioNMeAiliimn. 13 Test Hale CI Other <br /> nym6erofwel9 �'••� ouwberarbwinp 0Gemechn e.1 nmuboorborinar <br /> ❑Monitoring Wells) Oil Borings) <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement 11 Pump Repair ❑Cross-Conne,ion Repair ail <br /> WELLCONVrRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary 11 Auger ❑Cable Tool 0 Push Point �therLf/[CP/' <br /> Proposed Well Depth�R Excavation in diameter 0Open Bottum ❑Gravel Puck/Gravel Si <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter_in ThickeWGauge/ASTM Schad O Steel ❑plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth It ONeat Cement(941h bug15-I0gal water) ❑Sand Cement .rorknos17 gal wnmr <br /> ❑Benlonite(20%Solids) ❑Manufacturer Spec%Solids_% Name ❑Specson File ❑Specs Submitted <br /> Grant Placemen(Method 0 Pumped C3 R.Fall Cl Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller O Pump Contractor 13 Other <br /> O Concrete Pedestal Dimensions: Width It Lmgth A Thick in ❑Christy(los 13 Move Pipe <br /> POMP 0Submersible 11 Turbine El Other HP Pump Sat_11 Standing Water Level 11 <br /> WELL DMRUCIION ❑Open Bottom ❑Gravel Peck 0 Uncased 11 Other <br /> Well Diameter in Total Depth It Depth to Water It 0 Casing to be Perlbrated from it to Il <br /> Sealing Material Xnt Cement(94/h hug 15-I0gu/wate) ❑Sand Cement sock mh17 gd water ❑Bentonite Pallets <br /> O Bemonim(20%solids) 0Manofeetumr Spec%.lids % Name ❑Specsom File ❑Specs Senonned <br /> Placement Method ❑Pumped re,Fell ❑Other <br /> ❑Complete with Mushroom Cap It below grade ❑Complete to Existing Surface Ped <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 /> MINIMUM 24 IIOUR ADVANCE NOTICE REQII IRED POR INSPECTIONS <br /> SIGNED TITLE DATE <br /> A. <br /> ITC tjfAu <br /> K L— <br /> • <br /> —f A UI G UN Y <br /> 42 <br /> �ntTM <br /> DEPARTMENT UIn <br /> Application Accepted BYI-o Data Arae Gnployre IDN <br /> Grow Inspection By Date 11SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVERReCeived <br /> Destruction Inspection By Date Co..Oared Well Depth It <br /> COMMENTS <br /> PE SC Amount Chackq/ Recelve0 Permit/ <br /> Codes nfo Remitted Cash B Dule Service Re u s InvOlttp WeII IDN <br /> 3' <br /> 3 <br /> ElID43.02-006 ��'t"t ��pv MASTER WATER WELL PERMII' <br /> snrz6o2 � • <br />