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Q IN CO VV hLL / YU1VlY r. <br /> SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH K1Vlj� <br /> NON-REFUNDABLE PERMIT a RTMENT <br /> 304 E WER �E 3k°FL-STOCKTON CA 95202 - (209)468-3420 <br /> *-.=CALL Z09 953-7697 FOR IN$PEcrtoiv$ EXPIRES ] YEAR PROM DATE ISSUED <br />' JOB ADDRESS 360 W, Bowman Road <br /> CROSSSTREET / �� rCITY/Zip French Cam 95231 m <br /> APN -Z� <br /> OWNER NAME Consuela Noce �� PARCEL SIZE <br /> OWNER ADDRESS 'same PRONE 9 0 Yn <br /> CONTRACTOR Delta Stockton 1DuI11 CITY/STATE/ZIP <br /> CONTkACTORADDRESS 646 S. California Street PHONE 466-9625 <br /> SUBCONTRACTORCITY/STATE/ZIP Stockton CA 95203 <br /> SUBCONTRACTOR A DDRESS PHONE <br /> LICENSE ❑C-57 ❑ CITY/STATE/Zip <br /> 13 D-09 ❑Other NUMBER 724778 <br /> GEOGRAPHICAL INFORMATION: Coordinates X EXPIRATION DATE <br /> Y Township INTENDED USE 1f1 Domestic/private ❑]rrigation/Agricultural p Range Section <br /> ❑Public Water System ❑Industrial ❑Water Quality MOnitorin <br /> y g ❑Soil Sampling/Characterization <br /> Ifdifferent From Owner: <br /> water ystem ame <br /> TYPE OF WORK C3 New WellReplacementamad ame or one Number <br /> ❑ Well ❑Well Alteration/Modification ❑Test Hole <br /> ❑Monitoring Wetl(s) numberofwells ❑Other <br /> number ofborin s <br /> ❑SOi]Boring(s) s ❑Geotechnical number of borings <br /> 13 Well Destruction . ❑Out-Of-Service Well <br /> ❑New Pum EXPum Re lacement 13Pum ne air ©Ow-Of-Service Well Renewal PPP <br /> WELL,CONSTRUCTION ❑Cross-Connection Re air { <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth tl Excavation <br /> in diameter ❑Open Bottom 0 Gravel Pack 1 Gravel Size <br /> 13 Conductor Casing in diameter / Conductor Casing Depth in diameter <br /> Well Casing Diameter in Thickness,/Gauge/ASTM Schell��� ❑Sp ft <br /> Grout Seal De th teel Plastic ❑Stainless Steel q Other <br /> p ft ❑Neat Cement(941h hub/3-l0gal water) ❑Sand Cement <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Namesuck mix/7 gat water <br /> Grout Placement Method ElPumped 13 Free'Fall 11Other ❑Specs on Elc ❑Specs Subm'tted <br /> ❑RetardantlAccelerator(name) �, F <br /> PEDESTAL Installed B Cl Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick " <br /> PUMP ❑Christy,Box". 111_#-vPtpe <br /> �r. <br /> Submersible ❑Turbine ❑Other Hp <br /> V-2 <br /> Pump Set 15 ft St ndi' a <br /> WELL DESTRUCTION ❑Qpen Bottom ❑Grave]Pack ❑Uncased + ,I(gj S r1evel: 20 tt <br /> ❑Other " <<Mw F <br /> Well Diameter in Total Depth 13 Depth to Water fi ❑C <br /> Sealing Material ❑Neat Cement(94 Ih hub/5-10 but water) 13 Sand Cement 'ertorated fro ft td: H <br /> sack rata I �veter ❑,Bentonite Pellets. <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name , p Specs on File= .❑Specs Submitted• <br /> Placement Method ❑Pumped ❑Free Fall 0 Other r Az <br /> P ft below grade ❑Complete;to xisti[tg 5urt <br /> Complete with Mushroom Caace:P,ad lt . <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK°WIILBE DONE I ". <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO C A'T' FIV THA L2IQRUIRED.CE WITH SAN <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BICENSE IS <br /> OARD AND='THAT 1 A117' COMkIANCELWITH ALL <br /> WORKERS COMPENSATION LAWS. t <br /> UM 24 HOUR ADVANCE NOTICE REQUIRED FO R'INSPECTIONS•: <br /> SIGNED TITLE DATE 11/15/02 <br /> YL I <br /> G <br /> I <br /> «F „ I <br /> r - r „ <br />_- _ ___-- --- - -- - DEPARTMENT US ONLY - - <br /> Application Accepted ByO¢, � "�� Date L 'Zr Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection y t �� Date lid ' ❑ WAIVER Received <br /> Destruction Inspection B Date Constructed Well Depth ft <br /> COMMENTS e, <br /> PE SC AmountCheck#/ Received Date Permit/ Invoice# Well[D# <br /> Codes Info Remitted ash By Service Request# <br /> EHD 43-02-006 <br /> 5n/2002 MASTER WATER WELL-PERMIT <br />