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rr i:r�rJ'r i utrir r�,lt�.trx�� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3"°FL-STOCKTOry CA 9;Affi z09)468-3420 NON-REFUNDABLE PERMIT CALL 2l 33-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROA 1'E ISSUED 1 l �+ �J C-�w,�1 � Joe ADDRESS "1��, �7. r� CITVIZIP kT-a- t/ Ck V dJ34 y /� p CROSS STREET APN -Ot 6t,1" PARCEL SIZE Lj, 63 �0[ 1 �e�� 1�l �Qlctyti PDGVX G$S 6kliltTy1T �Q�aPIlONE OWNER NAME -- OWNERADDRESS CONTRACTOR 10Q .Btack'dS` AJ /1-5 4 rYPHONE CZCS'\, p,—2L��+1^iF CITY/STATE/ZIPCONTRACTOR ADDRESS SUBCONTRACTOR PHONE FSUBCONTRACTOR ADDRESS CITY/STATFJZ1PP R `Y LICENSE ❑C-57 ❑C-61 ❑D-09 [her/��'r 's2 NUMBER 3d EXPIRATION DATE 3� O GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section INTENDED USE r Domestic/Private ❑Irrigation/Agricultural Q Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System F Irdiffcmntfmm Owner. mer ysrm ame ontact ame or one um TYPE OF WORK ❑New Well ❑Replacement Well ❑WeH Alteration/Modification ❑Fest Hole ❑Other f { ❑Monitoring Well(s) numberorwelu ❑Soil Boring(s) numhvofhorinbs ❑Geulechnical numberorborings k ❑Well Destruction ❑out-Of-Service Well ❑Out-Of-Strvice Well Renewal ❑New Pump ❑Pump Replacement Pump Repair ❑Crass-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other (` Proposed Well. Depth ft Excavation in diameter ❑Open Bottom Cl Gravel Pack i Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Dcpth it Well Casing Diameter_in ThicknesslGaugvJASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seat Depth ft ❑Neat Cement 04 lb bag/S-10 gat w rer) 11 Sand Cement suck mix!7 gal water ❑Bentonite(2Da/o solids) ❑Manufacturer Spec°/a solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant!Accelerator(name) PEDESTAL Installed By 13 Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width R Length_11 Thick in ❑Christy Box ❑Stove Pipe PUMP /d Submersible a Turbine P Other HP Z Pump Set_13_0 R Standing Water Level_ (QR WELL DESTRUCTION ❑Open Bottom ❑Grave]Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water fl ❑Casing to be Perforated from ft to tt Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mis 17 gal water Q Bentonite Pellets Q Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name Q Specs on File 13 Specs Submitted Placement Method CI Pumped Q Free Fall ❑Other ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad I- 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <~ MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS i. SIGNED TITLEDATE j NC 13 DEPARTMENT USE ONLY /f� C,Q� . 1 Application Accepted By Date U/:13��J Area Employee ID# f71 r-'1q Grout Inspection By Date 11 SPECIAL Well Permit Pump Inspection By Date V� 3 ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft ' COMMENTS YQ. M YL t-k i3O L3u'cb Y5 min j t PE SC Amount 42hec Received Permit! Codes Info Remitted Cash By Date Service Request N Invoice# well 1D# k 143 D 05 5 I,3DD > v3 .R 0 R r EHD 43-02-006 MASTER WATER WELL PERMIT J snn_oo2