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-,AAA, / PUMP PERMIT �s AC SAN JOAQUIN COI1N'I'Y I'iNVIRONMFNfAI.I II:Al.1'11 DEPA;�Ir r 314 E WRIIF..K AVq.W FL-S'1'(R'K'I'ON CA 952112 - (1119)468.34211 NON-REFUNDABLE PERMIT ('At,[,(209)953-7697 FOR INSPR(A IONS EXPIRES 1 YEAR FROM DATE ISSUED m JOB ADDRESS CITY/LIP e"/f�/l^D-f� 1 Jii m CROSS STREET - / Q1� APN I "Ism) I PARCELSIZE OWNER NAME �0"Wf��'L �^P'IIONf: ,1 OWNER ADDRESS ,f3 Gre.s�rif' -� CITY/STATE/ZIP SLQs //.LI ey 9s066 CONTRACTOR L PHONE 5,9 - y'5-b// CONTRACTOR ADDRESS S-r- CITY/STATE/ZIP/5p"� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER X+ EXPIRATION DATE A GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE El Domestic/Private 11)rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chamcterization ❑Public Water System If different from ner: atcr 'stem eme onlad ame or one um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ,Other .SQh ❑Monitoring Well(s) num ❑Soil Boring(s)berofwells numberofborings 0Gccitechnical numherofborins ❑Well Destruction ❑Out-Or-Service Well ❑Out-Of-Service Well Renewal Cc r M1ts. pf3� ❑New Pum ❑Purnp Rc laccmcnt KPump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth Il Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94/h bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20"/o solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall O Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width R Length—fl Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible O Turbine ❑Other lip Pump Set It Standing Water Level Il WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncascd O Other Well Diameter in Total Depth � Il Depth to Water Il ❑Casing to be Perforated from Il to It Sealing Material ❑Neat Cement(94 lb hag/5-10 aPb l wafer) ❑Sand Cement .sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. i 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 COMPENSATI AWS. MIdWA U 7 ADVANCE NOTICE REQUIRED FOR 1 SPECTIONS— PLEASE CALL(209)953-7697 SIGNED TITLE DATE T \41 FA IT G T E VI DE M DEPARTMENT USE ONLY Application Accepted By Date/�'� Area„1/� Employee ID# ,p Grout Inspection By Date ❑ SPECIAL Well Permit �3y Pump Inspection By Date .I Q3 ❑ WAIVER R¢C¢iV¢d - Deatrucdon Inspection B Date onstructed Well Depth COMMENTS PE SC Received cheew Amount Permit/ Codes Info B �C)ash Remitted Dale Service Request—V7 27 fl InvofceN We111DN I 4'/ d a 7 �.CiG �� s2 EIID43-02-006 MASTER WATER WLLL PERMIT 1?/6non?