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`�1l WELL / PUMP PERMIT �/ <br /> SAN JOAQ13IN COUNTY ENVIRONMENI'ALHEA LTII*1R'1'MEN'1' 304E WF.Dr:x el.3-FL-SrOC11ON CA 95202 - (209)468-.1420 <br /> NON-REFUNDABLE PERMIT CALI,(209)9.9-7697 FOR INSPE(*TRISS EXPIRES I VEAR FROM DATE ISSUED <br /> JOB ADDRESS _ -/ Crry/Ln• <br /> U/ -5 '�Ir'�[� a <br /> 77 <br /> 4�4 <br /> LAND USE APPLICATION#CROSS STREET %PN � 3 PARCEL SIZE <br /> OWNER NAVE PHONE A: - 1I FC/y <br /> pn°o <br /> C) <br /> OWNERADDRESS ' -j lG ; CITY/STATE/ZIP R <br /> CONTRACTOR r L' / { -(�( PHONE <br /> CONTRACTOR ADDRESS L n 1 .{.. <br /> ~K S CIT\'/STATE/LIP /✓ 3k <br /> SUBCONTRACTOR \ 17 PRONE <br /> SUB(YINTRA(-EOR ADDRESS V / <br /> 1'rY/STATE/ZIP Cl <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other �' MIME ER .'t ? L <br /> EXPIRATION DATE Z J <br /> GEOGRAPRICAL INFORMATION: Coordinates X V Township Range Section_ <br /> INTE.NDVD II,SF. .Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If MrR.nl from Owste <br /> ner: ager ym ame Contact Name or FIF-orelqu-mlier <br /> TYPE OF WORK ,KNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> O Monitoring Wel l(s) #ofwells ❑Soil Boring(s) korbonngs ❑Geotechnical eof borings <br /> O Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal \_ <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method )Zj.1ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other A� <br /> Proposed Well Depth) R Excavation I in diameter ❑Open Bottom XGravel Pack/Gravel Size in diameteq , J <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 42 <br /> In ThicknesS/Ga �uge/ASTM Sched (-a ❑Steel XPlaslic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /c.'' ft ❑Neat Cement(94 lb hag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Manufacturer Spec%solids % Name — E)Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ElFree Fall �❑.,,O1,ther ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Bax ❑Stave Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneosed ❑Other <br /> Well Diameter in Total Depth D Depth to Water R ❑Casing to be Perforated from It to fl <br /> Sealing Material ❑Neat Cement(941h hag/5-10gn1 water) ❑Sand Cement .rack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free I all ❑Other <br /> ❑Complete with Mushroom Cap tl 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. 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 /> I <br /> MINIMUM 2 HOUR ADVANCE NO'FICE1\REQUIRED FOR INSPECTIONS <br /> /1 <br /> SIGNED l ��(C. � I�/-t� )'L54'" TITLE—hI GY' DATE <br /> C <br /> C <br /> _ U1 ( <br /> IR N <br /> H )t", c 4 <br /> U <br /> 1 <br /> / DEPARTMENT USE NL <br /> Application Accept ' <br /> Date D Area Employee ID# <br /> Grout ins clion_Uy' - `J7 Date C1 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Dale Constructed Well Depth ft <br /> COMMENTS -� <2' - <br /> i <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uesl# <br /> MASTER NATER WELL PERMIT <br /> EBD 41-02.aon <br />