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WELL/PUMP PERMIT ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3m FL-SEOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED se r g� Po JOBADDRFSS CITYrDr n y P pD 1♦ CROSS STREET APN 1z O(L �'=1 PARCELSIZE 14 LAND USE APPPP]LICATION# p te�OWNER NAME PHONE r OWNER ADDRESS / CITYMATFIZIP T�HI ` AAz hu, CONTRACTOR 5111A Z VM CONTRACTORADDRESS CITY/STATE/ZIP gURCONTMCTOR PHONE 91110 SUBCONTRACTORADDRESS CITY/STATFJZIP '/ LICENSE 0 C-57 0 C-61 ❑0.09 Other /O NUMBER EXPIRATION DATE !o 1 GEOGRAPHICALINFOORRMATION: Coordinates X Y TDWnahip Range_ SKBon RauINTENDED USE 2mmeISIM/Private ❑InigallOn/AgrieultUml Cl Industrial ❑Water Quality MOniwnug ❑Soil Sampling(Characterimdon ❑Public Water System IrdIR(from tamer r ysmm arae LanUtl Tracor Flaom Nurner TYPE OF WORK ❑New Well'' ❑Replacement Well ❑Well Alteration/Modification ❑Test Hale ❑Other Bs O Monitoring Wcll(s) No(wells ❑Soil Borings) IONV..m ❑Geotechnical aMlwnnas r 0 Well Destruction ❑Out-Of-Service Well 0Out-0f-Service Well Renewal ONmPomp 4fumpReplacannent ❑Pump Repair ❑Crus-Connection Repair 1 WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cattle Tool ❑Push Point ❑Other — '� Proposed Well Depth R Excavenon in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sire in diamelm ❑Conductor Cuing indlameter / Conductor Casing Depth ft v Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Stcel ❑Plutic ❑Stainless Steel ❑Other , Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 ga/water) ❑Sand Cement sWknuml7gafwata t`aa ❑Bemmnits(20%solids) ❑Manufacturer Spec%solids % Name ❑Spas on File b Specs Submitted Grout Placement Method ❑Pumped ❑Free Fa11 130th.,— ❑Relarchem/Accelerator(tame) PEDESTAL Installed BY ❑Diller O PUMP Contractor ❑Other C, ❑Concrete Peclattl Dimensions: Width ft LAmgth ft TlUck in 0 Chat",Be. ❑Stove Pipe 't C r PUMP ,JkS.b.ible ❑Turbine ❑Other HP Pump Sai.�{ fl Starling Water Level it WELL DESTRUCTION ❑Open Bottum ❑Gravel Peck ❑Unused ❑Other I Well D(amctcr in Total DMtA ft Depol to Water ft ❑Casing m he Perforated from ft in ft Sealing Material ❑Neel Cemenl(94/b bag 15-/0ga/wamr) ❑Sand Cermet sack m¢/7 gal water ❑Bcnmoite Pellets ` 0 Bentonite(20%solids) ❑Mareacturer Spec%solids % Name ❑Specson File CISpas Submitted Placement Method ❑Pumped ❑Fra Fell ❑Other ❑Complain wiN Mushroom Cap ft below grade 0 Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAW$AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENTA IVT HTIIETA'Lt NIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL N WOR COMPEN N W WS. n 11N OUR ADVANCE NOTICE UIRED FO INSP ACTIONS $ICNE TITLE DATE R. P �r r NI VieO C Application Accepted By DEPARTMENT USE ONLY DDowArea -3)1_ Employee IDN / �' Gmut Inspection By Due */ ❑ SPECIAL Well vedlllll Pump Inspection By Date J ❑ WAIVER Received LDestruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Chee Amount Data PermiD Invoice# well ID# Imas Codes Info B Cash Remitted ServkeR uut# OS /390 0 D C' 's L EHDllA3-ea6 MASTE0.WATER WELL PERMIT IYll/[W]