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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUMV ENVIRONMENTAL IIEALTN DEPARTMENT 304E WEBER AVE 3"1`1.-STOCRTON CA 9$202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209]953-7697 PDR INSPEC11ONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBABDRESSR <br /> I/7JO�h E' T(.rNIaT � CITV/ZIP -t` cC a <br /> ET <br /> CROSS STRE4COA /Cr-( API 1+1 -110 - l/ PA.1.112P. 4-'. 4.3 a <br /> OWNERNAMEp � PHONE r//y77.),OWHERADORESR X401� H--&IW4i+ LMCITY/STATE/ZIP Ttacy <br /> CONTRACTOR Cay aiLt! DL,16mg PHONE <br /> COMMCT(HRADBRESS zzQ 7� <br /> QISSSn <br /> CITY/STATE/ZIP <br /> SUMONTGCrOR_ PHONE <br /> SUBCONTRACrORADDRESS CMI'STATE'LIP <br /> LIcimsE u111557 00.61 0D-09 E3 Other NUMBER E%PIIUTION DATE <br /> GEOORAPHICALINPORMATION: Caordlnehr X V TonnsWp Range &e Chn_ S <br /> INTENDED USE PLD..UdPnwac ❑Irriga ion/AWicultsul ❑IMustdal 0 Water Quality Monitoring ❑Soil Sampligl/Cluiaeteriation <br /> O P.M.Water System <br /> Irmm­owr.ber. u.r nam era --Ca—�w rum u <br /> TYPE OF WORK )`New Well ❑Replacement Well O Well AlamiaMdadifiutian 0 Test Hole D Other Crj <br /> ❑MoelleringWells "uO'h"°raxlb nwnbrr ofbannm a., r ormnnys <br /> O ❑Soil Bming(a)_ ❑Cc=ahnical <br /> 0 Well Destruction ❑Out-OGService Well DOut-Of-Service Well Renewal <br /> Cl New Purre ❑Pump Replacement Cl Pump Repair 0 Cm s Conn ed.Rcusir <br /> WELL CONSTRUCD <br /> Drilling Method Mud Romry .6]Air Rotary ❑Auger ❑Cable Tool 0Push PoitN ❑Other <br /> Proposed Well Depth ft Excavation in diameter 0Opm Bottom ]1(bOvcl Pack/0U, el Sia CO PQ;l n diameter <br /> OCmMuclor Casing indiemour vi <br /> / CondVeun-Cang Dcpth _fl <br /> Well Casing Diameter��4in TbiekneLJGaugtlASTM Schad (GU 19f2 ❑Steel xPlestic ❑SMinles Stat 13 Other <br /> "�S <br /> Crout Seal Depth 4W108 ❑Neat Cenecot(94 lb bag)S-/Bgol wvhrJ 03and Ccmrnt Fuc$an.07 gat water ¢ <br /> O Benlonne(20%solids) O Manufactumr Spec%solids_% Name Ca-pt Ir��-1� ❑SpEuonFile OSpn;s Submiucd <br /> Grout Placement Method ❑Pumped ❑Fra Feli E3 Cuter. ❑Reluctant/Accelerator(name) <br /> PEDESTAL Installed By 13 Driller O Pump Contractor Kocher <br /> O Concrete PadeMal Dimeaalom: Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 0Submooeble ❑'ILrbine ❑Other__ HP__ Pump Set_ft Standing Water level R <br /> WELL DESTRUCTION C3 Open BMtem ❑Gravel Pack 0Uracased ❑Other <br /> Well Dia=emr io Tohl Depth It Depth in Water h ❑Cuing Ito be performed frm RIn—0 <br /> Sealing Materiel ❑Nen Cement(94 lb bug)J-/Oga/werer) 11 Sam Co..( .anckaix/72alwater O Bemmnite Pellets <br /> ❑Ben=nim(20%solids) ❑Manufacturer Spa%solids_% Ne=e ❑Speccou File ❑Spees Suhmitled <br /> Placement Method ❑Pumped 0I I.Fell 0 other <br /> 0 Complete with Mushroom Cep R below grdr. ❑Complete to GiRing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALT. <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE 5EQUIRF,D FOR INSPECTIONS <br /> SmNED T17u /J�,�ra�_ <br /> DATE <br /> Y <br /> n <br /> U am <br /> DEPARTMENT USE ONLY�Y <br /> ;Accepted d , Doh -1'� rY Aha 2I Date 2,2�2 ❑ SPECIAL Well Permit <br /> Date ❑ WAIVER Received <br /> Destruction In •tion By ♦ Deus Constructed Well Depth_ / D <br /> COMMENTS_ v6L O L G u ff(t311PTk' ( $r (R aFl•42@s,f., -&Or(p P 7` <br /> FIPE SC Amount RatDale rmlt/ InvoiceIt Well ID@ Info Remitted Cash <br /> d 225 3 3105 <br /> EHD43-02-006 MASTER WATER WELL PERMIT <br /> SM-1002 <br />