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WELL 1 PUMP PERMIT <br /> SAN JOAQU IN COUNTY ENVIRONMENTAL Io~H DEPARTMENT 304 E WEBER AVE 3"l �SzvCRTON CA 95202 -(209)458-3420 <br /> NON-REFUNDABLE PERMIT I�I CALL 249 9q--X7/]697 FO INSPECTION'S EXPIfi,_.1 YEAR FROM DATE ISSUED j <br /> 3OSADDRE58 /J //�� 0�fff1 ` 0D x CITYIZIP I <br /> -�h,QV�• vX����r� PARCEL SIZE I O 7qe <br /> i° CROSSSTREFT APN ,Z,— �_ <br /> I � J /�a c/.y� <br /> OWNER NAME PIIONES��`?) ! <br /> t ty t <br /> OWNER ADDRESS745� I ICITYISTATEIZIP t� l(c,�„r� -O �1L_A, P <br /> CONTruCCDR �j �J•—� Yrti . PRONI ,[�,, ogC 1Y�}� <br /> CONTRACTORADDRESS 36 CITYISTATFILInr—/ (�1'r.•._� !r+y_i <br /> SUBCONTRACTOR PHONE1 <br /> SUACONTRACYORADDRE$$ SIA CITYISTATT/ZIP <br /> VW <br /> License C-57 C-61 ❑D-09 ❑Othtr NUMBERIL ExrIRATioN DATE I� <br /> 992V <br /> GEOCRAPHICALINFORMATION: Coordinates X Y Township Ranitc Seclion {— <br /> INTENDED USE DomesticRrivare O IrrigalionlAgrlculturat ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Cbatacterization `a1 <br /> CI Public Watt,System <br /> Vdiffrmmtmm aer. W.— ynem ante <br /> TYPE OF WORK ❑New Well ❑Replacement Well 0 Well AheratiunlModirmation ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) .ambernfrcus p Soil Barings) ^u,,rbo i.p ❑(ieoteehnical n.mberorborinyx <br /> C7 Well Destruction ❑Out-Of-Service Well 13OuL-Of•Service Well Renewal <br /> ❑New Pum Pum Renlacemcnl ❑Pump Repair ❑CrnSs-CDnnp tion Repair 1 <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Eseavetion in diameter ❑Open B6llDm ❑Gravel Pack!Gravel Size in diameter <br /> OConductor Casing in diameter 1 Conductor Casing Depth _ti '•` <br /> Well Casing Diameter_in T iickntasrGaurJASTM Schad ❑Stecl O plastic ❑Stainless Simi ❑Other <br /> Grout Sea! Depth A ❑Neat Cement(941b hag•/340gal wafer) ❑Sand Cement sock mixt 7 gat water <br /> ❑Bentonite(20%solids) 17 Manufacturer Spec%solids % Name ❑Spm un File ❑Specs Suhmined <br /> Grout Placement Method 0 Pumped ❑Fra Fell ❑Other ❑Relardam 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor Cl Other <br /> ❑Concrete Pedestal Dimensions: Width_ li Length_B Thick in O Christy Box ❑Stove Pipe <br /> PUMP Submersible OTurbine ❑Other_ HP Pump Set II Standing water Leve! R <br /> WELL DESTRUCTION ❑Open Bottom Cl Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Dcpth R Dcpth to Watcr A ❑Casing to be Perforated from A to fI <br /> Sealiat Material .17 Neat Cement(94 fb hug13.10gal"ter) ❑Sand Cemen[ ruck Mu 17 gal water ❑Bentonite Pellets i <br /> Cl Bentonitt(209:solids) ❑Manufacturer Spec%solids__% Name ❑Specs on File ❑Specs Submillcd <br /> Placement Method ❑Pumped 0 Free Fall ❑Other_ <br /> 0 Complete with Mushroom Cap fl below grade ❑Complete to Existing Surface Pad i <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TMAT 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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MIN2 HOUR ADVANCE NOTICE ' /IRED FOR INSPECTIONS <br /> SIGNED �J %ITITLE r��J<E'11Q'✓� DATE <br /> i <br /> NRI I <br /> ILL!mv <br /> I <br /> I <br /> CE i <br /> Yii , IrJ <br /> DEPARTMENT EONLY <br /> Application Accepted By Dare � 03 _ Area Employee IDN a <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspeciion B Datc l4 L O3 Q WAIVER Received <br /> Desiruction InSptction By Date Constructed Well Depth R <br /> COMMENTS <br /> PE I SC Amount Chec Received PermiV <br /> Codes Inco Remitted Cash BY Date ServleeR uestN Invoice Well IDN <br /> O '� Ibb z�G D /PLD <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 517/2002 <br /> I <br />