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WELL/PUMP PERMI'I' SAN JOAO,UIN COUNTY ENVIRONMENTAL HEALTII DEPARTMFNT 304 E WEBER AVE 3"FL-STOCK"I ON CA 95202 - (209)46$-3420 HON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRE 1 POOH AT-ISSUED JOE ADDRESS [/C/ N�/O ' [(/n'� 1 l-L—�(1-��A fly CITV/LIP CROSS STREET \L - C,OAaI. APN PARCEL SIZE I r V OWNER NAME S not OWNER ADOPESS CITY/STATEIZIP_ I``[Xk"r-71Y. (T7 JS 3.5 1 " CONTRACTOR R R.J A-Z T-e�� ...tM L PHONEl-`�i`/y.SO CONTRACTORADDRESS -7 3 10 wast- l U`C,VATI V"t-.�d-()� CITV/STATEIZIP Ctn hnttC„�3( . Cy SDRC-ONTRACTOR � j �t{� PHONE OVQ 1 -yWS—(f'7/ I '0 SU13CONTRACTTORRADDRESS ,x-310 C�7 G[11r\ L.J6 lex, ,1Y1 yl-e-� CITY{/tiTATi/ZIAP 3 LICENSE P<"57 ❑x_-61 Cl D-09 ❑Other NUMBER EXPIIL/TION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Ranee Section INTENDED USE ❑Domestic/Pnvate ❑Irrigation/Agriculturel ❑Industrial ❑Water Quality Monitormg Z il Sampling/Characterization ❑Public Water System IfditUremrram Ow er n yuem me antsci omit or nit um TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altemtion/Modification ❑Tot Hole OOther_ ❑Monitoring Well(s) ""'"b`rorwdlr 2loilBoring(s) "'-jQ °O1nlxrorpo"nyw ❑GCoteehnital _ numberorn«, s O Wcll Destruction ❑put-Of-Service Well ❑Out-Of-Service Wcll Renewal ❑New Pump O Pump Rco_lacement ❑Pump Repair ❑Cross-Conneciion Re it 4LL COW""Atas,C-s:, IAL* WELL CONSTRUCTION1 Drilling Method ❑Mud Rotary q Air Rotary ❑Auger ❑Cable Tool C1 Push Poin: dOther /YC/ ow,�FI Proposed Well Depth_?-�; _,ft F.xcavetion in diameter ❑Open Bottom ❑Gmvci Pack/Gravel Size in dlamcier , ❑Conductor Casing in diameter / Conductor Casing Depth T ft Well Casing Diameter_in ThickneWGG c/ASTM Sched ❑Steel ❑Plrstic ❑Stainless Steel D Other Croul Seal Depth�_ft g7 Nea1 Cemtnl(94!h bag/SJO gal wrer) ❑;and Cement —ck mir/7 gal water ❑Bentonite(20"/6 solids) O Manufacturer Spa%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall Olhcr Vjnfl a- p /t�/�� O Revrdam/Accekretor(name) PEDESTAL Installed By O[hiller O Pump Contractor OOcher ❑Concrete Pedestal Dimensions: Width__ In Length ft Thick in O Christy Boa ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other_ HP__ Pump Set fl Standing Witter Level Il WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Ucpth to Water Il O Casing to be Perforated from ft to ft j Sealing Material ❑Neat Cement(94!h hug/5-10 gal some,) ❑Shnd Cement_ sock mu 17 gal water ❑Bentonite Pellets (I ❑Benconne(200/solids) Q Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Plaremenl Method ❑Pumped Q Free Fall ❑Other ❑Complete with Mushroom Cap tl below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND *CHAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. t ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. UirN i.0el'A* / ]I HOeUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS � �(do- IV" //� � SIGNED y2 .-1�-� ,��dt1�7F� (1(1, r TfI'LE �C�/�— DATE LY/ W V-� IV!n 7 -Vt all �• r wr.q •� � war'"� -�1� • r Application Accepted By 2_b Date Area E IF4 1O9 IDN Grout Inspection By Date ❑ SPECIAL Weil IPl17it Pump ln7spccdn By SiiMa_�rDDraaattee 1-1l itWs nAI+VEfR HRDwAeived Constructed Well Depth rzuon By Insy�YCOMMENTS 400 R s rrst av+yI/t fie r v;aog!sn.or 8.IC1 s ' w 1 jot —� PE SC mount heck#/ ReceivedP r Codes Infu Remitted as B Date ervrmRc uest# Involve# WelllD'y i{ 72 50 "03,0&"- ..................... b2 �Ub EHD43-02-006 MASTER WATER WELL PERMIT chhM'.