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��7y/ WELL/PUMP PERMIT <br /> SAN JOAQUIN CO T ENVIRONMENTAL HEALTN DEPARTMENT 304E WEBER AVE 3""FL-STOCKTON CA 95202 ,(209)466-3420 <br /> NON-REFUN BLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> Joe ABDREs$ / n <br /> CITYIZIP <br /> Clean STREET <br /> A 7D• O fae <br /> APN F 3 PARCELSIEE <br /> qI <br /> OWNER NAME LT NE -2/-V QI fe Jlzaj <br /> n <br /> G <br /> OWNERADDRESSCITV/STATE/ZIP <br /> CONTRACTOR <br /> ONE <br /> CONTRACTOR ADORESb CITYIETATFJZIP {J I <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCYIMRACTOlt AOOREW CITY/STATVZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Othet O NUMBERKPIRATION DATE Q� <br /> GEOCRAPmCALINFORMATION: Cpordinatn X Y Township_ Range_— Section_ <br /> INTENDEDUSE i</Privele ❑IrrigmeVAgncultuml ❑Industdel ❑Water QYahry Monitoring OSoil Snmpling/Chamcterimtion <br /> ❑Public Water System <br /> Rare ISea, 'w,ar�-----,u>Sy:mn�aem— ,"a .meol -,� r <br /> TYPEOF WORK ❑New Well ❑Rapine...Well 13 Well Alwatiore Modifieauon ❑Test Hole ❑Other <br /> numb,of welly❑Monitodn Well(s1_..._._ Soil BonngOs _ ❑Gcotechn—lal —'— <br /> aumenofemml \ <br /> Cl <br /> Well Dmwction OOut-Of-Service Well DGUPOI'-Service Well Renewal <br /> O New Pum m2 Replumem, C3 Pum R it ❑Cross-Connection Repair <br /> WELLCONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Romry ❑Auger pCable Tool DPush Point ❑Other ` <br /> Proposed Well Depth R ExCasretion in diamHtt ❑Open Bottom OGmvel Pack/Gravel St. <br /> __in diameter \Vl <br /> ❑Conductor Casing___iodiamew / Conductor Casing DNN.,,,______tl <br /> Well Casing Diameter__in Thicknesa/Gouge/ASTM Schcd OSteel ❑Plaaic ❑Sminless Steel ❑Other <br /> Grout Seal DapN R ❑Nat Cement(94 lb/x`6/5-10gR1 ware,) ❑Soon Cement lock mix/T gal water <br /> ❑Bentonite(20-Asolids) ❑Mnnuhcmrcr Spec%solids ^/e Name lock <br /> File ❑SPecs Submitted <br /> Grout PHttAent Method ❑Pumped ❑Free Fall ❑Other 13 Retardant/Accelemmr(came) <br /> PEDESTAL Installed By ❑Niter ❑Pump Contractor ❑Other <br /> E3 Concrete PWMMI Dimendom: Width—It Length R Thick in OChrlaty Bos ❑grovepipe <br /> Pump Submersible 13 Turbine ❑Other HP Pump So H Slanding Water Level R <br /> WELLDESPROCTION DOp.,Bmmm OGmvt Pack OUncaxd ❑Other p <br /> Well Diameter_in Tom[Depth A Depth to Water D ❑Casing to be Perforated from_ft W_ft 1- <br /> Sealing Material O Neat Cement(941b hug 15-/0gol wetter) ❑Sand Cement sack cake/7 gal water ❑Be Montt.PoheQ /• <br /> ❑Hematite(20°b solids) ❑Manulacturor Spec%mlids_% Name ❑Specsan File ❑Specs Submitted <br /> Placermal Method ❑Pumped ❑Free Fall ❑Other 7a <br /> ❑Complete with Mushroom r— fl below glide ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE.IN ACCORDANCE WITH SAN (V <br /> JOAQUIN COUNTY ORDINANCES, STATE W WS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS Q <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INIMUM 24-MOV DVANCE TICEREQUIRED IONS—PLEASE CALL(209) 697 <br /> SIGNE TITL <br /> DAT¢ � 7 <br /> Y <br /> N <br /> A M T <br /> •- DEPARTMENT U N Y <br /> Application Aelicned By Dara 4P2,to Area r.2(8 Employee[D# <br /> Grout Irupcction By _ ///___ Dole ❑ SPECIAL Well Permit ' <br /> Pump Inepeadon By n iall pate ❑ WAIVER Received <br /> Destmcuon Inspection ____,.._ Date Constructed Well Depth 0 <br /> COMMENTS <br /> • PE SC Received ChePKgl Amount Perm1U <br /> Cadet Info B m RemlBed Data $ervlceR ueatq InvoiecN Wall IDN <br /> 43 0 3o•vJ Oo m <br /> EXD ql-02-006 <br /> 12/6/1002 MASTER WATER WELL PERMIT � <br />