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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTtl DEPARTMENT 344 E WEBER AVE 3--PLA SrocKTVN CA 9= -(209)468-3420 NUN-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPEC-nONS EXPIRES 1 YEAR FROM DATE ISSUED to Joe ADDRESS _ `� t ��At V/;C .C.T11a., CROSS STREEr APN�'Nn.3.f—G L 4PJAJ�RICLL SIZE/ O"ER NAI>IE 7� V PHONE / v Z'L 0 s f (hwNERADDREfS k2_�jy1 L' C17YISPATTMP �4 CONTRACTOR �A ye, PHONE ,� -el,l--/z7L CONTRACTOR ADD... O It�a CITYISTATFAIP SURCONTRACrOR PIKME SVBCONTNAt,TORADDRYSS NC 4— 4J C[TWSTATEErLirr /r LICENSE >V:-57 ❑C-61 ❑D-09 Cl Other NUMBER !73C7"' EXPIRATION DATE [a � t GEOCRAPHICALIMDORMATION: Coordinates X V TovmcMp RAnge Sest4sn INTENt)ED USE ❑DomesticlPrivate Tri tion/A ricultural m❑Indusuial ❑Water ' ga & Quality Monitoring ❑Soil SatnplinglCharacteriurion 0 Public Water Syattnn Hdirr trmm � '�-"i':ary-1 FIMK v er TY►r.OF WORK til a Well ❑Replacement Well ❑Well Altexarion/Modlfiearion ❑Test Hole ❑Other ❑MDnimein Wells tMab"or—ji, O Soil Borings) numberufbetngs 00cotechnical "amber ofbw,"fR ❑Well Desuuction E3 Out-Of-Service Well 0 Out-Of-Service-Well Renewal jj&ew Purnp ❑Pump Repilsezmen1 ❑Pump Repair ❑Cross-Connection Repair W Es.L C0,4EMUCT[OR Drilling Method>G&MudRotary 13Air Koury ❑Auger 0 Cable Tool ❑Push Point ❑Other -y Proposed Well Depth L,Sf7 ft Excavation in diameter ❑Open Bottom XtimA el Pack I Gravel Sine in diameter r�,, ❑ConductDrr Casing in diameter / Conductor Grsing Depth ft Well Casing Diameter O in Thic4nemlOBuge/AS i M Schcd•1--00 a Steal Mastic ❑Stainlrss Steel Cl Other Grout Sal Depth_--_ _0 it ❑Neat Cement(941b berg/5-10 got twrrar) 3�I`Sand Cement. f i) suck mix 17 gal water 0 Bcnronite(204:solids) ❑Ma UfA0tureT Spoc 46 solids_% Name_ ❑Specs on File ❑Sot"Submitted Grout Placement Method mped O Free Fall ❑Other 0 Retardant/Accelerator(name) PEDESTAL )Installed BY b4vri0er 0 Pump Contractor 0 Other ❑Concrete Pedestal ea Z rionr: Width R Lengthl� ft Thick in ❑Chrla Box ❑Stove Pipe Pump ❑Turbine ❑.Other HP--S- Pump Set R Standing Water Ltvel ft WBta.DESTRUCTION 0 Open Bottom ❑Gmvd Pick M Uncascd 0 Other Well Diameter in Total Depth R Depth to Water n ❑Casing to be Perforated from ft to it Sealing Material ❑Meet Cement(94 1h bug 1540gai twuer) ❑Send Cement m k mix 17 gal water ❑Bentonite Pellets 0 Beetnnita(70r%Wi4s) ❑Manufacturer Spec%solids_% Name O Specs on File ❑Specs Submitted Placement Metitod ❑Pumped ❑Free Fill ❑Other ❑ComPICIC with Mushroom Cap fr beiow,grade ❑Complete to C-isting Surface Pad E HEREBY CERTIFY THAT I 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 CALIPORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN1MLVMk4H0U ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697U SIGNED /Ar— TITLE C?RwAI'^ DAT. 1 1 a i� - PARTMENT USE NLY Application Acceple(y - Dote L Area Emplaycc ION00 Orout Inapecti " - Date S IC3 SPECIAL Well Permit r 1 (( Pump Inspapon By Date �Q/r7y r] WAIVER Received Destruction Inspa:tiun BY Date Cotrstr eted Well Depth n I �1 EN15 .-`ea [i li-E SC Received fjecW Amount deDate Ptrmlt/ Invateo# WeIlID4 Cos Infe B ash RemiService Request N GG%'57e,f CHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002