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WELL I ruIVxr IMruv11>< <br /> (209)465-3420 <br /> 304 E WEBEF' E 3""FL-$TOCKTON CA 95202 - t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH W_' RTMENT :__ (AIRES l YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMITcri <br /> S tCALL 209 953-7697 FOR INSPECTIONS rn <br /> CITYIZIP <br /> JOB ADDRESS <br /> ... PARCELSIZE c <br /> APN ' <br /> CROSS STREET rn <br /> PHONE <br /> OwNizR NAME <br /> i CITYISTATEIZIP <br /> OWNER ADDRESS - <br /> PHONE <br /> CONTRACTORr u <br /> CITYISTATEIZIP <br /> CONTRACTOR ADDRESS <br /> PHONE <br /> ! SUBCONTRACTOR <br /> C ITYISTATEIZI P ,/rr <br /> SUBCONTRACTOR ADDRESS <br /> EXPIRATION DATE <br /> LICENSE g C-57 ❑C-61 ❑D-09 ❑Other <br /> NUMBER <br /> � yTownship Range Section <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization < <br /> INTENDED USE amestic/Private <br /> ❑Public Water System offer ystem ante ontact ame or one um er <br /> I Ir different from caner: �t <br /> erTest n <br /> TYPE OF WORK ❑New Well eplacement Well [3 Well Alteration/Modification number <br /> ❑Other numberofborings <br /> ❑Monitoring Well(s) �-- <br /> numberofwells ❑Sail Boring(s) 13Geotechnical <br /> ❑Well Destruction ❑put-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Putrip ❑Pump Replacement fl Pump Repair Cl Cross-Connection Repair <br /> WELL CONSTRUCTIO <br /> Drilling Method ud Rotary fl Air Rotary ❑Auger ❑Cable Tool ❑Push Point Other t, <br /> Proposed Well Depth�.T ft Excavation� in diameter' ❑Open Bottom ravel Pack 1 Gravel Size in dialneter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth 1t <br /> Well Casing Diameter _jL in TbicknesslGaugcIASTM Sched ❑Steel HIrastic ❑Stainless Steel ❑Other C` <br /> Grout Seal Depth ^ft ❑Neat Cement(94 lb hub/5-10 got water) ❑Sand Cement suck mix!7 gal water <br /> 91'Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> k <br /> � Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> 4 PEDESTAL Installed BY L3 Driller ❑Pump Contractor they lf <br /> fl Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine 0 Other HP Pump Set ft Standing Water Level tt <br /> i WELL DESTRUCTION pen Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter—6—in Total Depth _?ef ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 Ih hag/S-!0 gal water) M Sand Cement suck inir 17 gal water 13 Bentonite Pellets <br /> lId'Bento.mte;( %solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method Ml<umped ❑Free Fall ❑Other <br /> Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI N LAWS. <br /> MINI M 24 HOUR-ADVANCE NOTICE #QUI . D FCTIONS <br /> I <br /> SIGNED TITLE DATE17 <br /> Q <br /> G - <br /> 1 <br /> v. <br /> b S <br /> N <br /> AO R i <br /> 1 <br /> N - <br /> DEPARTMENT USE ONLY^� <br /> Application AcoBy <br /> 1� w`W Date LI ©' _ Area 2-15 Employee ID# A <br /> Grout InspDate �'cy�I ❑ SPECIAL Welll, Permit <br /> Pump InspDate ❑ WAIVER Received <br /> Destruction lnspDate r/ C� Constructed WeiI Depth A � ftCOMMENTS <br /> PEC <br /> Amount Check Received Permit! <br /> Codes Info Remitted ash gY Date Service Request# Invoice# Well 1D# <br /> 3 190 zz 3SM-7 � C SIS 00 3 PAyf q2 <br /> OG a 3S �" r 3 5 10 P-s <br /> SHD 43-02-0067pVFJIpf LL PER t <br /> 5/7/2002 SAN$LIONE� ERVICE5 <br /> 1;NVI�tONMENY�^.L�I�AL�H D1V1310N..r, <br />