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WFLL/PUMP PERMIT SAN JOAQVIN COUNEY ENVIRONMENTAL HEALTH DEPARou 304 E WEBER AVE J~FL-STMITTON 02 -019)46"30 NON-REFUNDABLE PERMIT CA 9 953-7697 FOR INSPECTIONS EXPIRES 1 VEAR A'&�DATE ISSUED �n JIM ABORI'.SS 1/07(o Al //'+ 99L—ilsf/w+ ��4_�f'a�cTrvl'/,Ir �O d4 e-/9 . 9_,p_V0 D CROS4STaELT 9'/I71(frQ d./ APN �)59- � /P'ARCELSIZE J (7s) yEv. OWN E.RNAME /TMD,ell see X4eP Pnone l-Z�/19� 3L 8-`7,PZ OWNERADORLSS /.2SOZ (s.-, ,r �4 .GCMRTAT ./, '.4- /SZX-O VIP �" c•G CONTRACTOR Pr10NE: _z "� CONTRATTOR ADDRESS CITU/STAWZIP !e 5 cr--,Ic i_ 'JC L 7 SUBCONTRACTOR PHONE SUB'IWTRA(TOR ADORf51% CITV/Sl'ATF/ZIP UcinSE Cl C-57 0 C`61 DD-OD OOther NUMBER E%PIRATIONDATE GET)GRAMHCALINFORMATION: Cood1.11.1 X Y TDwnahlp_ Range_ Scellan INTENDED USE ❑Dnmaatic/Private ❑ImgatioNAgriculmml ❑Indosuial ❑Water Quality Monitoring ❑Soil Si mpling/ChalacNtlmlion ❑Puhhc Water System it d.Nenm from= ..51c.1mm ConWINAmemPhimsNuamer TVPEOFWORk 13New Wall O Replacement Well Well Altmtion/Modincation 13 Test Hole ❑Other O Monitoring Well($) wmbm.r.dl. 0Soil Borings) umbnorburin5. 0Gemethnical .umMrorbonny ❑Well Destruction ❑Out-0f-Servitt Well ❑Out-0f-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connmlion Repair WYLL CH.N.STRUMON Drilling Alathd ❑Mud Rotary ❑Air Rmary ❑Auger p Cable Tool 0 Push Paint OOther Proposed Wall Depth fl Eaavalion to diameter 13 0'.Bottom ❑Gravel Pack/Gravel Six in diameter ❑Conductor Casing in diameter / Condi eser Casing Depth n Well Caring Diammer_in Thiekness/Gauge/ASTM Schad 13 Steil ❑Plastic ❑Stainless Stttl ❑Other Gmm Seal Ihpth A ONut Cement(94/6hug/5-10 gal wider) 13 Sand Cement NLk m&/7 gal water ❑Rcnmute(20%solida) ❑Manufacturer Spec V,Solids % Name ❑Spoeson File ❑Spoes Submincd Grout Placemenl Method ❑Pumped ❑Free fall ❑Other ❑Rclnrdonl/Accelerator(name) PEINSTAL installed Br ODriller ❑Pump Contractor ❑Other D Concrete Pderttl Dlnrenslans: Width R Length R Thick in ❑Christy Bm 0Mew Plpn Pump ❑Submersible C3 Turbine 0Other HP_ Pump Set R Standing Waier Level O WELL DisamUCTION ❑Open Be".. ❑Gavel Pack O Unused 0 other Well DiameternToul Depth R Depth W Water R O Caving to Inc Performed from_R to_Il Sealing Material ❑Neat Cement(94 n,h.,15.10ind wuler) ❑Sand Cement and mu/7 gal.,or ❑Bemonim Pellum O 6emmins,(2MA solids) ❑Manufacturer Spec%solids_%. Name OSpecson File OSpecaSibmilled Placement Method ❑Pumpul ❑Free Fall ❑Other Cl Complete with Mushroom Up Il below grade O Complete to Eaisting Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY JEEQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI U HOU ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL((�2N0/99,Ny)//t9tar5--3aT--�..77L697 $M.NEO .� TITLE DpryrtaVtE"T-e) I' C. The well must be repaired under permit and inspection by the Environm bivlsion (San Joaquin County Development Title,Section 9-1115.4(e))as follows: I. Install cement surface seal around the well casing to protect the Well casing sufficiently and the integrity of well grout. 2. Provide sample tap prior to pressure tank. Page 1 of 2 ADivuionoI`San Joaquin County Health Care Services Aptim....Arcapd Hy (/iC'. ��J Date //U��JI-T Arca "III Employee IDR %l-T 1 Gnus=a i Data -s ❑ SPECIAL well Permit 91gf Pump 1n.Cmat m 11 Data ��i/mA ❑ WAIVER RKe{Yed 7 AMrvOxw ImrAm1—y Dale 4 COBTluld"all Details—BR ('400 N 5 sl & 0. ir a G— y'__arm C K Resell fk$aYl Alment Dale Per.IV baMnR win IDT R6aa tale B Nemlud WrrheN unte 5 ,-E63 1 t U at41 OIM MASTER WATER WELL PERMIT