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" WELLIWMP PERMIT <br /> USNT <br /> , AN JOAQmN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3'FL-STmOroN CA 95202/)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR PROM DATE ISSUED <br /> JOBAUDRE56 L/si G• �- ( CN/2,P <br /> 0 <br /> CROSSSTREET /�/f C / APN PARCELSIZE v <br /> OWNER NAME //l2We'4r41yu4 �4a� AAA I-A PROBE <br /> /(d5z� <br /> OWNERADDRM _l"•0" Aoxn Jl,A_ I I CITYISTATEIZIP <br /> CONTRACTOR Y4e'�n /-iPHOO- �.NNEEf T! I�YJ �-r•�� <br /> CONTRACTORADDRLSS (/U�-J �1 r1-Ze- T <br /> S . CITYA � C-' <br /> TATEIZIP 7Cc���y�rZr✓J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATFIZIP <br /> LICENSE 0 C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> CEOCMPIIICAL INFORMATION: COOrtllnales X Y TBwmhip_LI5 Range_jf��Section <br /> INTENDED USE O DomealirlPrivate ❑Inigmin/Agriculomil ❑Industrial O Water Quality Monitoring XSmI Sampling/Chataclenratirm <br /> 0 Public Water System <br /> IrdiDerenlrmm Owner. Witter Soernlt.nte omam arrear ne ton" <br /> TYPEOF WORK 0 New Well ❑Replacement Well 0 Well Aluxation/Madifo:ati0n ❑Test Hole ❑Other <br /> O Monitoring Welt(s)_ umxr Rfweib g -ii Boring(s) n""w"arominn ❑Gmltthniwl -mbarermrinp <br /> 0 Well Des roclion 11 OUI.O6Service Well 0Om-Of-Service Well Renewal <br /> 0 New Pump 0 Pump Replacement ❑Pump Repair 0 Cross-Connection Repair <br /> WELL CONSTRUCTION q <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool 0 Push Point MIher lJlCCP/' <br /> Proposed Well Depth r R Excavation in diameter CI Open Bottom ❑Gravel Pack l Grovel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in ThicknesslGaugerASTM Sched 0 Steel 0 Plastic 0 Stainless Steel C!Other <br /> Grout Seal Depth R ❑Neat Cement(94/h hug/5-/O gal mover) 13 Sand Cement mak mu/7 gal water <br /> ❑Bemonite(20%solids) 0 Msnu amumr Spec%solids_% Name ❑Spas on File O Specs Submined <br /> Grout Placement Method 0 Pumped 0 Free Fall 0Other ❑Retardant/Accelemtor(name) <br /> PEDESTAL Installed By 11 Driller ❑Pump Contractor ❑Other <br /> 0 Concrete Pedestal Dimensions: Width_ R Length_R Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP_ Pump Sat R Standing Water Level It a <br /> WELLDESTRUCTION ❑Open Bottom 13 Gravel Pack 0Uncased ❑Other <br /> Well Diameter_in Total Depth R Depth to Water R 0 Casing to be Perl'om cd from—R to R <br /> Sealing Material )<eat Cement(941h hng1540gol miter) 13 Sand Cement ruck mix 17 gal water O Bemmmim Pellets T <br /> ❑Bemonite(20%solids) ❑Manufaclumr Spcc%solids_% Name ❑Specson File ❑Specs Submitted a <br /> Placement Method 0 Pumped lst'Pree Fell ❑Other <br /> 0 Complete with Mushroom Cap R below grade 0 Complete to Existing Surface 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 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> 1q <br /> Ell I- <br /> • OA UI L' UN <br /> DEPARTMENT USE Y <br /> Application Accepted By 1 Date Area Employee ID# <br /> Grout Inspection By Dam ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVERReceiVed <br /> Destruction Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Amount Cloce"I Received PermiU <br /> Cotler n10 Remitted Cash By Data Service R u s N Invofeeq Well IDp <br /> 3. <br /> END 43-02-006 �� @.�pv MASTER WATER WELL PERMIT <br />