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WELL 4jMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 364E WEBER AVE 3"FL-STOCKTON CA 95202.4611-3426 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .ry <br /> � �.�—r��,�.g•�„-;�fl, C tiV'.CE= 2�tP <br /> /� <br /> CROSS STREET }}/)t-k /•Jr) /(f")�� PpARC�C(L SILE p <br /> OWNERNAME i //j /t' '3 IYL /PRONE <br /> OWNER A000.E$E V &C CITY/STATE21P <br /> CONTRACTOR � PIRRO,E�I�/)TO,—n <br /> CONTRACfORADDRESS CITY/STATFIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE 13 C-57 Cl C-61 0D-09 ❑Other NUMBER ExPIRATIIorN DATE y <br /> GEOGRAPNICALINFORMATION: Coordinates R Y Township L.J Renge� Section -C <br /> INTENDED USE ❑Domeslie/Privme ❑IrrigaliontAgricultural 11 holm trial ❑Water Quality Memnon, oil Snmpling/Chmmmization <br /> ❑Public Water System <br /> Ifddferemtrmm Owner: Water Systan Name ContociNanwarPlamall,rear <br /> TYPEOFWORK 13 N.Well ❑Replacement Well . ❑Well Alanotion/Modifleation ❑Test Hale 'Other _^.I%✓�trmPl� <br /> ❑Monitoring Well(s) mambermfwAl Borings) -^L nuvZT1badngr ❑Geomchnical unherofbarl <br /> ❑Well Duwclion ❑ -pMI Ouun-Of-Service Well 0Out-Or-Service Well Renewal <br /> ❑New Pump O Pump Replacement ❑Pump Repair 0 Cross-Connection Re it <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool 0 Push Point ❑Other <br /> Proposed Well Depth_A Excavation in diameter 13 Option Bottom 17 Gravel Pack/Gmvel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth Il <br /> Well Casing Diameter_in Thickn ne/GaugauASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0Other <br /> Grout Seal Depth R ❑Neat Came.t(94 Ib h WIJ-IO Red nrcrrer) ❑Sand Cement rnek rnix/]gel water <br /> ❑Bentonite(206/a solids) 0 Manufacturer Spec%solids % Name ❑Specs on File ❑Spas SubmRwd <br /> Grout Placement Method ❑Pumped O Free Fell 13 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Connector Cl Other <br /> ❑Concrete Pedestal Dimensions: Width It Length U Thick 13 Christy Box 13Stove Pipe <br /> PUMP 13 Submersible 0Turbine 0Other HP Pump Set—11 Standing Water Level 11 ) <br /> WELL DESTRUCTION ❑Open Bottom 13 Gns cl Peck Cl Uncned El Other <br /> Well Diameter_in Total Depth It Dpth to Water R ❑Casing to be PerlbmlcA Door_B to R <br /> Sealing Material Feat Cement(94 is lRrg/5-IOgtil miter) 11 Sand Centaint stick mix/7 gal water O Bemonite Pellet T <br /> O Bcntonite(20%solids) O Manufacturer Spec%solids % Namc OSpecson File ❑Specs Submiped 4 <br /> Placement Method ❑Pumped )arae Fall 0OtheT <br /> ❑Complete with Mushroom Cap A 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. 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 DVANCE NOTICE REQUIRED F R INS/PECT ONS <br /> SIGNED TITLE tTC DATE <br /> IT <br /> JItAE,UHit <br /> � ,�sarl DEPARTMENT USE ONLY <br /> Application Accepted By�-9/I t k �E-f-� Data . wa— Area Employee IDg <br /> Gout Inspection By Dete ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Deswction Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Amount Checks/ Receive Date Permit/ InyOieeis WeII IDp <br /> Cod., Into Re.Itid Cash Service Request s <br /> o ed 3 22 <br /> 3 <br /> EHD 43-02-006 -1"7D MASTER WATER WELL PERMIT <br /> 5nr2062 <br />