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.. > VV r,uj. r r 1V1T11 i -+_�•,}_— _ (209)468-3420 <br /> 1 i <br /> 304 E WEBER AyE 3""F <br /> It 9411 <br /> SAN JO UIN COUNTY ENVIRONMENTAL HEALTH ° RTMENT F*11(PIR, ATE ISSUED <br /> rONDABLE PERMIT ;ALL 209 93-7697 FOR INSPECTIONS ( C <br /> CITY/ZIPCIAPN ED <br /> w <br /> 110NE <br />! OWNERNAME 4 'v" V {( �('J� CI Q3or Gr <br /> CITYISTATEIZIPOG "-" <br /> OWNER ADDRESS h � � Q <br /> 1`J) PHONE_ <br /> CONTRACTOR r 0t <br /> CITYISTATE1ZtP <br /> CONTRACTOR ADDRESS <br /> `11C PHONE 11K� <br /> SUBCONTRACTOR <br /> CITYISTATEIZIP �"� �✓ -+� <br /> SUBCONTRACTOR ADDRESS �/ �16�T�� 6 <br /> NUMBER EXPII;ATfON DATE [r5 <br /> LICENSE C-57 ❑C-61;, 0 D-09 ❑Other �a'�o�`1 3B r�1e Section <br /> f 1 Or��jJ Township Range <br /> GEOGRAPHICAL INFORMATION: Coordinates X A {o �� 03�+7 Y, -- <br /> INTENDED USE ❑DomesticlPrivate ❑IrrigationlAgricultural ❑industrial ❑Niater.Quality Monitoring XS. <br /> INTENDED <br /> SamplinglCharactetizatiori <br /> ❑Public Water System stet ystem ame ontact ame or: one um er <br /> Vdifferent from Owner- <br /> TYPE OF.WORK ❑,New Well ❑Replacement Well ❑Well Alteration/Modification numtaofborinysTest le El Other numberofborings <br /> number of wells D Soil Boring(s) Geotechnical— <br /> ❑Monitoring We11(s) ❑Out-Of-Service Well Renewal <br /> [I Well Destruction. DOut-Of-Service Well <br /> ❑New Pum ❑Pum Re ]acement 0 Pum Repair <br /> ❑Ctnss-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depthft Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in°diameter'9 Conductoi Casing Depth' ft <br /> C3 Steel b,Plasuc ❑Stainless Steel 13 Other <br /> Well Casing Diameter n Thickness/Gauge/ASTM Sched ❑Sand Cement stick Mix 17 gal water <br /> C_ rout Seal Depth It ❑Neat Cement(94!h hug 15-10 gal water) <br /> ❑Specs on File ❑Specs Submitted <br /> r Bentonite(20%solids) ❑Manufacturer Spec%solids %„ Name 777 <br /> j v _ t� ❑Retardant 1 Accelerator(name) <br /> Grout Placement Method d Pumped ❑Free Fall ©Other <br /> PEDEST Installed By D Driller. . D Pump Contractor Cl Other S <br /> ❑'COncrete.PCdestaI`- Dimensions: Width tt Length 'ft Thick in ❑Christy Box [3 Stove Pipe <br /> �p� yp ;. Pump Set -' ft.. Standing Water Level tt <br /> POMP r7V`•'Submersible - ❑Turbine •.'`❑.other <br /> WELL DFSTRU ON 13 Open Bot_tofrt ❑Gravel Pack ❑Uneased <br /> ❑Other <br /> 4 ell Diameter in Total Depth tt Depth to Water tt Q Casing to be Perforated from ft to ft <br /> F <br /> + Sealing'1 erial ❑Neat Cement(94!h hag/S-!0 gulwurerj ❑Sand Cetnen[ sack mix/7 ga!water ❑Bentonite Pellets <br /> ❑Bentonite(20P/4,solids) :- ❑Manufacturer Spec%solids % Name [3 Specs on File ❑Specs Submitted <br /> Placement Method. -❑Pumped 13 Free Fall .'(Other p Complete to Existing Surface Pad <br /> p Complete with Mushroom Cap ft below grade <br /> a I 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 REGULATfbNS. 1 ALSO CEIiT1FY 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 /> WORK OMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE QUIRED FOR INSPECTIONS O p <br /> TITLE f DATE <br /> SIGN <br /> 4 <br /> .R9 <br /> t NV rj. <br /> i <br /> D ` <br /> tr <br /> 1 <br /> -- - oEPARTME T-US <br /> Area Employee ID' <br /> Z�W--/A <br /> pplicauon Accepted By � T� Date <br /> t Inspection <br /> Date ` 11 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Date Constructed Well Depth ft <br /> Destruction inspection.By <br /> COMIvIEAITS Z; ��W- <br /> 7' <br /> PE SC Amount Check# Received Date •Pertnitl Invoice# Well IDN Codes info Remitted Cas By Service Re nest# <br /> Z Deo 6 <br /> MASTER WATER WELL PERMIT <br /> EHD 43-02-006 <br /> j 5!712002 <br />