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WELL I PUMP PERMIT SAN JOAQUIN COUNTv ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCICTON CA 95202-(209)46&3420 NON-REFUNDABLE PERMIT CALL(209))953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Y Jon ADDRESS ��r ( --m/ 7—0 r� 1� CtTYIZIP G ((a y CROSSSTIMM r ]CY- ��`� III RM_ APN PARCEL SIZE q('3. v OWNERNA�M�E,r(�� PHONE ~�`1S OWNERADURESS CITYISTATFAZiP •► '''y CONTRACTOR } CONTRACTOR ADDRESS2J5 Vz CITYMATE1ZIP i,�,1 CA M] t0 ' SUBCONTRACTOR - PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE ❑C-57 0 C-61 ❑D-09 Cl OtherG NOMBE - EXPIRATION DATE 1 CE4CRAPHICAL INFORMATION: Coordinates X Y Township Range SeellOn ri�—T� 7 Domcstic/Private ❑Irrigation/Agricultural O Industrial 13 Water Quality Monitoring ' 13Soil Samphng/Ch3MC(1!nation ❑Public Water System lfdiffemmfrom veer: Werr SYSWn .— a .rear Pho. um TYPE OF WORK 0 Nev,Well Cl Replacement Well 0 Well AlterstiotVModiftcation 0 Test Hale O Other O Monitoring Well(s) rumberof"lls l]Soil Borings) number ofharinbn O Geotechnical numherorborirw Well Destruction 0Out-Or-Service Well D Out-Of-Service Well Renewal cw Pum Pump Replacement ❑Pump Repair O Cross-Connection Repair WELL CONSTRUCTION - + Drill Ing Method ❑Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool O Push point 0 Other Proposed Well Depth R Excavalion in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth R Well Casing Diameter_in ThicknessrGaugrJASTM Schod O SEcel O Plastic 0 Stainless Steel C3 Other Grout Seal Depth R ©Neat Cement(94 Ib hag/S-10 gut ware.) ❑Sand Cement rack mix 1 7 gal water D Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name .0 Specs on File 0 Spec&Submitted R1 Grout Placement Method ❑Pumped ❑Free Fall 0 Other CI Retardant I Accelerator(name) 1t PEDESTAL Instal 0 Driller ❑Pump Contractor ❑Other 0 Concrete Pedestal Dimensions: Width ft Length R Thick in C3 Christy Boa CI Stave Pipe PUMP Submersible 0 Turbine 13 Other HP Pump Set R Standing Water Level f, r WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack ❑Uncased 13 Other C Well Diameter in Total Depth ft Depth to Water ft 13 Casing to be Performed Ilrom R to tt Seacing Material ❑Neat Cement(Y4 1b hug/3-10gal we ler) 0 Sand Cement .rack.rix 17 gat water 0 Bentonite Pellets 11 Bentonite(2001,solids) 0 Manufacturer Spec%solids % Name ❑Specs on File []Specs Submitted Placement Method O Pumped ❑Free Fall 0 Other ❑Complete with Mushroom Cap R below grade Cl Complete to Ex4ting Surface Pad N 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1(�_ JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS �J CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �MIMUNI k4 HOUR VANCE N TICE REQUIRED F IN CTI —PLEASE C LL(2()9)9 3-7697 SIGNED TITL i.� DATE I A IJ 11111 M f t IN R N E DEPARTMENT N Application'Accepted By Data Area 2_k g Employ.l� Grout Inspection Date 13 SPECIAL Well Permit Pump Inspection y Date ❑ WAIVER ReCeived Destruction Inspection By Date Constmeted Well Depth ft ' COMMENTS PE SC Received a Amount Date Permit! Invoice Well ID# Codes Info Bv Cash Remitted Servit:e Rtguezi9 EHD 43-02.006 MASTER WATER WELL PERMIT 121612002