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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304EWESERAVE3-FL-STOCKTONCA95202 - (209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS Zi-{gam\ S. �IrC'A lzck. Crfv/zu, se <br /> St. AIN TIG 2� ° <br /> CROSS STREET Of J 'rX-N-2/yI PARCEL$1]E 3 9 <br /> OWNER NAME <br /> SeF� "CI C�2\cAR^� P0GQA 625 Enn,s 147 SR72PHONE9,S(es,-67-I3 <br /> b' OWNERADDRESS 7C16AsT s/GN rw lt�6!5CT/c2iIY641 IIIVG <br /> CONTRACTOR ✓A �' E� SGS G�. GT.�/e -PHONE gms.-74\vl <br /> CONERACTORADDRESS \�O �k \�� CITY/STATFIZIP E(•ACy Ck-I Qg37� <br /> SUBCONTRACTOR PHONE <br /> A <br /> SUBCOMMCTOR ADDRESS /�� CITY/STATE/ZI <br /> pP C <br /> LICENSE ❑C-57 13C-bl ❑D49 er 0 0 -A NUMBER 3! EXPIRATION DATE <br /> GEOGRAPHICALINPORMATION: CDOrdlnahT X Y Township_ Range_ Section <br /> INTENDED USE A Domestic/PtivMe ❑IrrigatiOWAgricultuml O Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chamcterimdon <br /> ❑Public Witter System <br /> UeTf fc Owns nw yimn -w un m m um <br /> Yart <br /> Twe OF WORK ❑NOW Well ❑Replacement Well ❑Well ABemtioNMadi6emion ❑Test Hole ❑Other <br /> ❑Monitoring WeH(s) nwa6wofw1r 11Soil Borings) nornin-flonn° ❑Gmtmhnical ^un�+oraadoa <br /> ❑Well Drswction ❑Out-0FService Well ❑Om-0f-Service Wall Renewal <br /> ❑New Pump 0 Pump Replacement XPump,Repair ❑CroesConnetionRepair <br /> ` WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tooi ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Batmm ❑Gravel Pack/Gravel Sian—in diameter <br /> ❑Conducor Casing indiarruner / Conductor Casing Depth B <br /> Bas Well Casing Diameter_ it ThickmNs/Gaugv/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth B ❑Neat Cement(94/h hugl S-10gal wider) ❑Send Cement swot robs/7 gel water <br /> 0 Bentonite(2(ysolids) ❑Manufacturer Spm%solids_% Name ❑Spoeson File ❑Spas Submined <br /> Grout Placement Method ❑Pumped ❑Fra Fell ❑Other ❑Rnardam)Accelerator(name) <br /> I,B, PEDESTAL Installed By 0Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensiane: Width_ B Length_ft Thick in ❑ChFsty Box ❑Stove Pipe <br /> PUMP ASubrnersible ❑Turbine gother HP Z Pump Set13Q ft Standing WaterLevel t7ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑UncasW 17 Other <br /> Bass, Well Diameter n Total Depth it Depth to Werra ft ❑Casing to be Perforated from_ft to a <br /> Sealing Material ❑Neat Cement f941h hug15-10guf wase,) ❑Send Cement seek mix/7 gal water, ❑Bentonite Pellets <br /> ❑Bentomite(20%solids) ❑Manuf:cmmr Spm%solids_% Name ❑Speson File ❑Specs Submiued <br /> Placement Method ❑Pumped O Fre Fall ❑Other <br /> ❑Complain with Mushroom Cap R below grade ❑Complete in Existing Surface Pad <br /> h. <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUI <br /> CURRENT <br /> N COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL- <br /> WORKERS COMPENSATION LAWS. <br /> Bass MINIMA g HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS •//T �r <br /> SIGNED TITLE VIUMU IPLh DATE / L Ol/ <br /> dna <br /> L <br /> r <br /> ST <br /> L w. <br /> DEPARTMENT USE ON �s ciq-©, <br /> Application Accep4d By Date -03 Area AI(I Employee IDM ^T <br /> Grout Inspection By Dow ❑ SPECIAL Well Permit <br /> 111s, Pump Inspection By /Pl/X/✓C�- Q�7 Dated�3_►U3 ❑ WAIVER Received <br /> Destruction Inspection By Data Constructed Well Depth H <br /> COMMENT$ Its c, <br /> PE SC Amount ba Received Data Permit/ Invoice# Well IDR <br /> Codes Info Remitted ash By Service Request N <br /> 113 SD 05 5 .00l3oD h n3 a LF <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 5naDmi <br />