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WELL 1 PIP PERMIT y ✓ <br /> LINTY ENVIRONMENTAL HEALTFt DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - �3420 <br /> NDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE tadUED <br /> ,S "}cam �! r7 / ,y��1 ,,/� - <br /> :S.S Z'I�! r- e I]AAf^r� r`fr /� CITVV//ZIP j.e0z e Cl'—"Y / q sz3. <br /> "I'Rt:t:T APN L� ��'��o(.20C PARCEL SI7.F. n <br /> .4ER NAME I!1 C3Af a A( A i12F G/Z' Yzzf9/0 rYea& C r -, PRONE b97— <br /> /INIA ADDRESS IZ e L r CITV/STATkILIP <br /> rCONTRACTOR A/,f.i V D+ - A55e-G _ PHONE -7 l - <br /> f <br /> f <br /> L CONTRACTORADDRESS �-� Np^rf T'e'( G/f CITY/STATE)ZIP 4-dl1> [ �7,+ <br /> SUBCONTRACTOR PIIONF, <br /> SUBCONTRACTOR ADDRESS t CITVtSTATEIZIP �{f <br /> �. LICENSE C-57 ❑C-61 ❑D-09 ❑Other 4NUMBER EXPIRATION DATE Qj 1.. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section '{ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Qua lity Monitoring Soil Sompling/Characterizaiion <br /> ❑Public Water System <br /> Irdifferem from Owner: Wnter.yslenl mix unmet oo nr one N­6c1 <br /> TvPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test I tole ❑Other <br /> nomher of wells numhcr Mbnrinr'` ❑(ieulechnical numberofborings <br /> ❑Monitoring Wcll(s) C�Soil Boring(s) U <br /> ❑Well Destruction ❑Oul-Of-Service Well ❑Out-OI"-Service Wcll Renewal <br /> ❑New PumQ El Pump Replacement ❑Pump Rc nir ❑Cross-Cunncctiun Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 13L Air Rotary Augcr ❑Cshlc Tool ❑Push Point ❑Other <br /> Proposed Well Depth_. R Excavation in diameter ❑ en B Gra Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 Conductor t <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched tccl 1 ❑ t inless Steel ❑Other <br /> Grout Seal Depth[y!t ❑Neat Cement(941h hug/5-101 d Cement .rack mer/7 gal water <br /> ❑Bentonite(2()%solids) ❑Manufacturer Spec%solids / Name % ,.r-/ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Dolle u Contractor ❑Other <br /> ❑Concrete PedestalDime Ir f ft Length_ft Thick in ❑Christy Box (3 Stove Pipe <br /> PUMP ❑Submersible ❑Turbine r 0 Other HP Pump Set it Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased Q Other <br /> Well Diameter_in Total Depth ft Depth to Water ft ❑Casing to be Perfor to from ft to ft <br /> Scaling Material 0 Neat Cement(94 1h hag/5-10 gal wager} ❑Sand Cement .ruck MU 17 gal water Sentanite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Specs on Pile ❑Specs Submitted ' <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVREQUIRED FOR,INSPECTIONS—PLEASE CALL(209)953-7647.. <br /> _I�f <br /> SIGNED TITLE - DATE y^L-_-1 - <br /> II �� r <br /> 1 <br /> lot J�j 07 <br /> I <br /> l i <br /> {I <br /> L <br /> i I m i <br /> P D PARTW n ...__ <br /> Application Aeeepted Ily Date <br /> �� • Area ��.f �� Employee ID# <br /> 1 Grout Inspection By N,1)ate ❑ SPECIAL Well Permit <br /> Pump nspectom IS RECEINE Il&ate ❑ WAIvrR Received <br /> Destruction spectio y Constructed <br /> /Well Depth R <br /> COMMENTS n E C <br /> PEte SC Received CWk <br /> h -# P rml! ]"voice# Well IDR <br /> Cada Info B Cash NVV&QWbjNT L baService Request# <br /> /L'.2 V n n <br /> ]iI1D 43-02-006 MASTER WATER WELL PERMIT <br />