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WELL/PUMP PERMIT <br /> SAN JOA&IN COUNTY ENVIRONMENTAL H4.-.H DfPARTMBNP 304 E WEBER AVE 31. -STocKTON CA 05202•(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES I YEd FROM DATE ISSUED <br /> �r1� � <br /> JOB ADDRESS . J CtTYIZrr d G <br /> CROSS STItELT /I!f I 1r(J.r-r�.. �(T___. APN -r—o�!3' ARCLLSI7Ss L40 <br /> OWNER NAMFi 7.-. Llrw 10 114 PHONE <br /> OWNER ADDRESS U.a- C1TYfSTATEMir f, <br /> CONTRACTOR r.A PRONE T Fiji, <br /> r^ CONIRACCORADDRESS 7 L CITYISTATE(LIP <br /> ` SUaCONTRACfOR PKONE <br /> SUBCONTRACTOR ADDRESS CrrY1St'ATLMP <br /> LICENSE A C-57 C-6 M D•09 ❑Other NUMBER E%PiRAT1oN DATE ' ti <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> !lIAAA INTENDED USE 0 bomestie/MVAIe O IrrigadoNAgricullural M Industrial ©Water Quality Monhoring 0S oil SamplinglCheractinintion W <br /> 13 Public Water System <br /> Ifditfortnt Imm Owa: ora yceem amo a omam aro a <br /> TYPE OF WORK D New Well O Replecement Well 13 Well AlteratioMModifreetioa O Test Hale 11 Other <br /> Af` numbaroTweus nwberofborig9s ❑GeotGhnical nmriber nTberEnry <br /> 11 Monitoring well(s) E7 Soil Bering(s) <br /> ❑Well Destruction ❑Out-Of-Scz irc Well 00ut-OfServise Well Renewal <br /> gN"PuM2 D Pu Replacement 0 Pump Repair 0 Cross-Connection Repair <br /> WELL CONSTRUCTION' <br /> Drilling Method Cl Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E3 Push Point ❑Other y <br /> Proposed Well Depth R Excavation in diameter D Open Bottom D Gravel Pack/Gravel Sias in diameter } <br /> "t O Conductor Casing in diameter / Conductor Casing Depth _ft <br /> Well Casing Diameter_in Thickness/Gaug&ASTM Sahed O Steel O Plastic E3 Stainless Steel Cl Other <br /> Grout Seal Depth R ❑Neat Cement IN 16 bag 1540 gal water) 0 Sand Cement sack mlr 17 gal water <br /> ❑Bentonite(20%solids) 13 Manuracturer Spec%solids % Name O Specs on File D Spt:cs Subrtlitted <br /> Grout Plaeemeat Method OPumpod D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESPAL larralled BY ❑Driller utrep Catlracto' 13 Other <br /> Comtrete Pedestal Dimenslons Width R Length�ft Thiok In E3 Christy Boa ❑Stave Pipe r <br /> PUMP KSubmersibk ❑Turbine (3 Other HP Pump Set ft StandingWater level IY�O fl <br /> J WELL DMItVCt9ON O Open Bottom D Gravel Pack 13 UDeased ❑Other <br /> Well Diameter in Total Depth R Depd:to Water ft ❑Casing to be Perforated from It to R <br /> Sealing Materiel E3 Neat Cement fY4 16 hog/5-10 gat wa(er) D Sand Cement sock mix 17 gal water 13 Bentonite Pellets <br /> D Beatonite(2oA solids) 0 Manufacturer Spec%solids_•% Name ❑Specs on Fite ❑Specs Submitted + <br /> Placement Method D Pumped ❑Free Fall ❑Other _ <br /> D Com letewith Mushroom Cap R below grade D Complete to existing Surface Ped <br /> 1 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> Fil WORKERS COMPENSATION LAWS. <br /> MINI 4 HOUR A ANCE N TICE REQUIRED IF INSPECTIONS-PLEASE CALL(209)9569 <br /> SIGNED TrrLE Y DATE 47 �1) <br /> kJ <br /> �I <br /> J. <br /> I UL <br /> TY <br /> Ct, R1 S UI <br /> (� <br /> 'coy <br /> 1 I DEPARTMENT USE 1 <br /> 11 JI Application Accepted By Date Q f Area + r Employes ID# 59��+ <br /> Grout Insyecricn By Date 6 CI SPECIAL Well Permit � <br /> Pump Inspection By Date /2: d EI WAIVER Received <br /> Destruction Inspection By Dere Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received rCheck9l.1 Amount Dale Invoice# WellID9 <br /> Codes Info B %emitted ServlceR test# <br /> S0 �V3 F 10 -o <br /> EHD43.02-006 MASTER WATER WELI-PERMIT <br /> 12/62002 p p <br />