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- - -- - 30' WELL/PUMP PERMIT �0 j� 1501 SAN JOAQUIN COUNTY ENVIRONMENTAL N t DEPARTMENT 304 E WEBER AVE 3'y, i.5 OCKTON CA 95302-(209)468-3420 NON-REFUNDABLE PERMIT CALL 2119 943-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED a M JoaAoDltFsS CITYIZIP CROSS STREET WW AA��' 71� APN PARCELSILE OWNER NAME J� J1 A29r: `ryCI'r7 C' .__ PHONE ' J-7 rf^ �,�t f i OWNERADDRESS ,1 I,3VO cp Y— r_ � CiTY/STATBIZIP_Ig//uI_ cJA �,RLSO� CONrRACrOR I�Tif G�Z�R�- fAz-' _ ,+.PP�H�-O�NEy -ps/�I r� CONTRACTOR ADDRESS �. � CtTYISTATF/Z., IIC.fAr�N CA 9Sa�aS "CONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISFATEIZIP LICENSE 1(C-57 13C.61 0 D-09 Q Orher NUMBER EX►IItATI(W DATE O GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INrRNDED USE 13 Domestic/private ❑lrrigation/Agricu{aural ❑Industrial Q Water Quality Monitoring fifeii Ssmplingtoarselerization ❑Public Water System 66 ne {rai[ferenrfrom Uwer ehx sy$tc. ams nsi 6me TwE OP WORK ❑New well ❑Replacement Weil E3 Well Alteratiorymadifica• It 13Test Hole E3 Other 0Monitoring Well(s) wmbmofwelis e,f•61 Boring(s) eumberorirm+ngs O Geotechnical Dwell Destruction 0 Gut4f-Service Well Q Out-Of-service Well Rodesval 5 ❑New Pump ❑Pump Rephicerrient El Pum air 0 Crass-CorinectioD Rgair WELL CONSTRUCROrt Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool Q Push Point ❑Other Proposed Well Deplh 06? A Excavation yin diameter ❑Open Bottom O Gravel Pack I Gravel Size in diameter ❑Conductor Casing in diameter l Conductor Casing Depth A Weil Caring Diameter_in ThickneWGaugcrASTM Sched ❑Steel ❑Plastic ❑Stainless Stec] ❑Other Grout Seal Depth ft 0 Neat Cement(94 16 bag/5-10 gat rwiter) O Sand Cement xm*mix!7 gal water C7 Bentonite(201/6 solids) O Manufacturer Spee%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped O Free Fall (3 Wier ❑Retardant I Accelerator(name) PEDESTAL 1011141M BV (3 Driller ❑Pump Contractor ❑Other E]Concrete Pedestal Dimensions; Width A I ength it Thick in E3 Christy Box E]Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It p WELL DESTRUCTION ❑Open Bottom O Gravel Pack E3 Uncascd ❑Other F Well Diameter in Total Depth ft Depth to Water R O Casing to be Perforated From It to H Sealing Material ❑Neat Cement(94 16 hag/5-10 gal wirer) ❑Sand Cement sack mer l7 gal water )R�Berttomte Pelkts Gs-TTT+6SS rF 'PXY G Bemonite(20%solids) 0 ManufacttrrerSpm%solids % Namc 0 5pecs on File O Specs Subtfitrtcd Placemeot Method El Pumped ❑Free Fail 13 Other d Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STAIT LAWS,AND RULES AND RECULAT]ONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIV ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKER MPENS LA NIMj ADVANCE NOTICE REQUIRED FOUR INSPECTIONS-PLEASE CALL(209)953-7697 SHINED TITLE)!?'STT rA)C.uEX-rt— _ DATEze'' '' OetY I ( 1 U I I DEPARTMEN NLY / Application Accepted By G�----1'r-t� Arra f-7 I12-- Employ-IDH (� Grout inspection By Dat, ❑ SPECIAL Well Permit Pomp lnspection By Date ❑ WAIVER Received J�Lnese ton ns ._ton _ Ewe_ 1 - mar steal Well Depth C')MME TS P£ SC Received CCheck l Amount Date Permit! Invoice Weil IDN Codas Into 8 as Remit Service Request H liq 2 3(o5�i 3 3 E - EMD 43-02.006 /j - �� sa MASTER WATER WELL PERMIT I 121612002 [+tsi✓ Tds -��t 49