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WELL i PUMP PERMIT SAN JOAQUIN COUNTY EpivistONMEarrm.. -rif DEPARTMfNr 304 E WEBER AVE 3'. i7OCxroN CA 45202 -(2 968-34 NON-REFUNDABLE PERMIT CALL(204)953-7b97 FOR 1.sPECTIo�s E)CPSRES 1 YEAR FRn3+•s DATE U ply JOB ADDRESS CITY'12, q 2 L2 FP P' CROSSSTREET APN� 7 C ` ! �C C/ T PARCELSIZE x OWNERAME. P HO N - - N OWNERADDRESS CIrY15rATe12lP 7 CONTRACTOR ` HONE CONTRACTOR ADDRESS ctrrrsrAT�ziP C F SUBCONTRACTOR P}IONE 4 A4Q SUBCONTRACT RADDRES5 CITYISTATrr4lP LICENSE G57 ❑C-61 ❑D-119 0 OlheF NUMBE ExpiitArioN DATE GEOGRAPII[CALINFORMATION: Coordinates K Y Township_ Range Section INTENDED USE mestielPrivam ❑lrrigatiordAgrieuitnral ❑Industria] ❑Water Quality Monitoring C3 Soil Sampling/Chanesterization ❑Public Water SyyS5Irc HIM..I rmmo� .ter Sy,tem arae C.WiNAw.rMae... J TYPE OF WORK ❑New Well Q Replacement Well (3 Wef[AlleratioNModiftcation fD Test Hole 13 Other Q Monitoring Well(s) number of weds ❑Soil Boring(a) n,,,r1"n;u ❑Gwlechnical numhm afborintp ❑Well Destruetton 11r S Out-Oervice Well ❑Out-0r--Service W0 Renewal ❑New Pum m Replacement. ❑Pump Reptir Cl Cross-Connection Reps i r WELL CONSTRUCTION Drilling Method Q Mud Rotary O Air Rotary ❑Auger ❑Cable Tool 0 Push Point ❑Other Proposed Well Depth 0 Excavation in diameter O Open Bottom O Gravel Pack I Gravel Six in 64MCref ❑Conductor Casing in diameter 1 Conductor Casing Depth_ fl Well Casing Diameter_in ThicknessiCauge/ASTM Sched ❑Site) ❑Plastic 13 Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 t6 fxrg/5-10 gat tvorc,) 0 Sand Cement ruck arty!7 gal water ❑Bentonite(20%solids) D Manufacturer Spec%solids_% Narne D Specs on File 0 Specs Submitted Grout Placement Method ❑Pumpcd ❑Fra Fall ❑Other ❑Retardant lAceelerator(name) PEDESTAL Iostalled Br Q Dnllcr ❑Pump Contractor 0 Other ❑Concrete Pedestal Dimenslattm Width_ R Lcngth ft Thick in 13 Christy Box ❑Stove Pipg PUMP ubrncrsible 0 Turbine 13Other HP Pump Sct ft Standing Water Level ft WELL DFSrRULTION ❑Opert Bolcom ❑Gravel Pack ❑Uaeased ❑Other Well Diameter_it) Total Depth R Depth to Waler fl ❑Casing to be Perrorated from ft to ft Sealing Material Q Neat Cement(94(b hug 13.10gal water) ❑Sand Cement .ruck mix 17 gal ureter 11 Bentonite Pellets Q bentonite(209A solids) ❑Manufacturer Spec%solids_% Name 6 Specs on pile 13 Specs Submitted Placement Method ❑Pumped Q Free Sall 0 Other El Complete with Mushroom Cap f[below grade ❑Complete tO Existing Surface Pad l HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUM COUNTY ORDINANCES STATE LAWS,AND RULES AND REGULATIONS. l ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS.COMPEN SATION LAWS, M NIP424 WD-)UR VA CE NOTICE REQUIRED R INSP CTIONS—PLEASE CALL(209)953-7697 SIGNED TITL r DATE ftc- li 6 N E .M DEPARTMENT USE OILY ` h r, at 0_ A r m qJ Application Accepted By 1 i O e A ee E ployee!DA' V Q Groutinspection By Date Q SPECIAL.Well Permit / pump inspection By are ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth h COMMENTS PE SC Received Ch Amount Date PermiU Invoke# Wel]IDN Codes into B Cash RamHeed Se mice Request 0 �Iq3 0 O�ZJ t�. 5 — D 1eM35s7f' '-2:.7 .O(_ EHD43.02.006 MASTER WATER WELL PERMIT 121fiP2002 l .. I