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?o' -.Q WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAtT TENT 304 E WroUr Ave 3i°FI.-STOCKTON CA 95202 (209)468,3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9 7697 F(IR INSPECrlONS EXPIRES 1 VOR FROM DATE ISSUED <br /> a <br /> JOB ADDRESS t7 9 / w CRy/Zwp t�- W M <br /> �^ <br /> Cfl0458772EET APN C/�/q7"�-- SO—OI PARCEL SIlL �-7 LAND USE AMACATIONM <br /> OWNER NAME !� • PHONE <br /> OWNER ADDRESS 'P— CITYISTATFMP rT <br /> CONTRACTOR PHONE S�d����LY2 <br /> ,t+I <br /> CONTRACTOR ADORE34 CITU ATFMP S irBCJL.�eA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTTIACTORADDRES9 CtTY/STATEIZIP <br /> C - <br /> LICENSE f*C17tJA^�1— OD-09 (3 Other NVMBERExPIxATtprI DATE <br /> GEOGRAPHICALINFORMATTON: COOrdleates X Y Township_ Range Section_ <br /> INTENDEDUSE Donicstic/Privatc 13 Irrigation/Agricultural 0Industrial 0 Water Quality Monitoring E3 Soil SamplinglChatecterixstion <br /> ❑Public water system <br /> If d'dforrut from Owner: W.WSyrmm me ac ame a <br /> TYPE OF WORK 13 New Well 0 Replacement Well d Well Alteration/Modification O Test Hole d Other <br /> O Monitoring wcn(s) #or wells a Soil Borings) w MhanuD 0 Ceolechnieal <br /> 13 Well Destruction Cl OulorService Well - ❑Out-Or-Service Well Renews] <br /> ew PUMP u Replacement O Pump ESMLT E7 CrossConnaction ReLmir <br /> WELL CONSTRUCTEON <br /> Drilling Method CI Mud Rotary 0 Air Rotary O Auger (3 Cable Tool ❑Push Point O Other <br /> Proposed Well Depth R Excavation in diamew 13 Open Bottom 13 Gravel Pack I Gravel Size in diameter <br /> 13 Conductor Casing in diameter 1 CenducWrCssing Dcpth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Scheel O Sled ❑Plastic a Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gal wafer) 0 Send Cement Sao mix 17 gal Water eI <br /> Q Bentonite(20%solids) O Manufacturer Spec%mlids_% Name p Speen on File O Spews Submitted O <br /> Groat Placement Method O Pumped 0 Free FalE 0 Other fl Retardant I Accelerator(name) N i, <br /> PEDESTAL lntlslkd By D Driller O Pump Contractor Dlhcr 01 t? <br /> oturete Pedestal Dimensions: Width It Length R Thick in E7 Christy Bos O Stove Pipe <br /> PUMP E<bmcrtribie O Turbine O Other HP P— Pump Set R Standing Waver Level I V7 fl <br /> Wcu.DEsTRucnoN O Open Bottom O Gravel Pack O Uncased e Other <br /> Well Diameter_in Total Depth ft Depth to Water ft E l Casing to be Perforated fivm ft to R <br /> Sealing Material O Neat Cement(941b bag/5-10 gal waver) O Seed Cement sack mix/7 gal water O bentonite Pellets <br /> O bentonite(20%solids) El Manufacturer Spa%solids_% Name ❑Spas on Fite 0 Specs Submitted <br /> Placement Method E3 Pumped O Free Fall Q Other <br /> 0 Complete with Mushroom Cap ft below grade Q Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 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 COMPENSATION LAWS. <br /> MIN M 24 HOUR ADVANCE NOTICES REQUIRED FOR INSPECTIONS <br /> TITLE SlGNEP TE � <br /> _. �t =rJ DATE /� a <br /> 4 <br /> 1 F41 Al <br /> - DEPARTMENT USE ONLY L <br /> Application Accepted By - Dane Area .� Employee ID# �Cf4T <br /> Grout Inspection By Date O SPECIAL Well Permit <br /> Pump Inspection Date [3WAIVER Received <br /> Destruction Inspection By. Date Constructed Well Depth B <br /> COMMENTSff.��7 Q'�9'�>/"�1�,}�t3I�L7lst�✓�{,��1GL/�i4,{���CGt�C � <br /> iZ�ib!J:nV(191!)/7!_ 1. �7 <br /> PE SC Received Amount Date Perntlf! <br /> CInvoke 0 We111D�A <br /> Codes Inre B Cash emitted Service uea 0 <br /> .dTi OSorwSp^di) -pp �-1 <br /> a2rA <br /> n1r}llaa]2-0ad <br /> MASTER WATER WELL PERMIT <br /> ]1 <br />