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VV zJL,1., 1 t tt-)iylr I ]u Xl—Lyxl JL <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT .304 E WEBER AVE 3"n FL- STOCKTON CA 45202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS PIRES I YEAR FROM DATE ISSUED <br />JOBAUDRE55 e, Pc4 ( CITv1Zn!��t✓-�`-"T� ( L <br />CROSS STREET tl'1� ©�1 S APN �4 `�•� PARCEL SIZE �. <br />OWNER NAME J �f Y'� PI[ONE <br />01 <br />2 <br />c CITYISTATEIZIP n� <br />OWNER ADDRESS 7 � �C- ��t'� r <br />CONTRACTOR Pf I S PHONE (� <br />CONTRACTOR ADDRESS ( 0 ✓ - r CITYISTATEIZIP pt F" <br />t <br />PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />❑ C-61 ❑ D-09 ❑ Other <br />GEOGRAPHICAL INFORMATION; Coordinates X <br />USP. ❑ 1)unkcslic/l'rivtttc ❑ lrrigutionlAgricultural <br />�Q Public Water SystCm �U1 no� <br />Ifdiflcrent from wnert +• 1'n rt-- ut` <br />CI'T'Y/STATE/ZIP <br />NUMBER jp�oe4FZ­ EXPIRATION <br />Y <br />Industrial <br />Township Ituuge Section <br />❑ Water Quality Monitoring ❑ Soil Samplin , Cltara` cierivAtion <br />natacn n}7•inc <br />1,171011C uw cr <br />TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlterationlModification ❑ Test Hole Otheriat 7-lr7+-,rELlsy�_/ <br />number of wells number of borings number of borings <br />❑ Monitoring Well(s) ❑ Soil Boring(s) ❑Geotechnical <br />❑ Well Destruction ❑ Out -Of -Service Well Cl out -of -Service Well Renewal <br />❑ New Pump ❑ Pum2 Replacement ❑ Pump Repair ❑ Cross -Connection Repair <br />•MELL CONSTRUCTiqN <br />Drilling Methodud Rotary ❑ Air Rotary ❑ Auger i/ 13Cable Tool ❑ Push Point ❑ Other <br />kmId <br />Proposed Well Depth_ ti Excavationindiameter fl Open Bottom gavel Pack /Gravel Size in diameter <br />❑ Conducta asmg in diameter ! Conductor Casing Depth fl <br />rt <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched - --7— fl Steel KPiastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth—,;2550-- ft ❑ Neat Cement (94 Ih hug /5-10 gid water) y$and Cement— 10. 3 .eac'k rnrx! 7 gal water <br />p(,Q}{ssifttis}� ❑Manufacturer Spec %solids % Name ❑Specs on File ❑Specs Submitted <br />Grout Placement Method umped ❑ Free fall Q Other i3 Retardant! Accelerator (name) <br />'SDESTAL Installed By ❑ Driller twtuDlp Contractor ❑ Other <br />_Concrete Pedestal Dimensions- Width ''�`--- ft Length ft Thick in ❑Christy Boz ❑Stove Pipe <br />PUMP ~ ❑ Submersible 0 Turbine ❑ Other HP Pump Set li Standing Water Level ft <br />WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Diameter in Total Depth R Depth to Water ft ❑ Casing to be Perinr ted from _— Il to 1l <br />Sealing Material ❑ Neat Cement (94 !h heig / 5-1 U};ul wedet) ❑ Sand Cement Sack rni.t 17 gal water 11 Itcntonite Pellets <br />❑ Bentonite (201% solids) d Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free fall El Other <br />C7 Complete with Mushroom Cap tt below grade ❑ Complete to lixisting Surlaee 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 1S <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />1/ <br />SIGNED I { f ` l . ) _ TITLE r, (it k -A - DATE Z-7SV- <br />r\ <br />Pump Inspection By Date ❑ WAIVER Received <br />Destruction inspection By <br />COMMENTS <br />Constructed Neil Dcplit <br />ft <br />PECAntouM leek# Received <br />Codes Info Remitted . s9r it <br />Dale <br />Permill <br />Service Request # <br />Invoice# <br />Well 1D# <br />1:111) 43-02-006 MASTER WA1'k.R WELL PERMIT <br />±,1713(x1: <br />