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WELL/PUMP PERMIT <br /> SAM JOAQum COuNTv ENVIRONMENTAL HEAI.TII DEPARTMENT 304 E W eaER AvE Sea FL-STOCKTON CA 95202-(209)463,MZ9 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DAIE ISSUED ��[7 <br /> Joe ADDRESS CA CITY1zIF <br /> CROWSTREET T APN -?-52--030-01 PARCEL SIZE-?1 R.C.G <br /> �//��''� <br /> OWNER NAM, PHONE-i-�ff-r -�i]/ <br /> 0"FRADDRMS CAI./IAO. A VITV/STATVzIr <br /> CONTRACTOR Pxone <br /> CONTRACTOR ADORES: CITYlSTATPIZIP <br /> SUECONr;axc TOR PHONE <br /> SuHCoNTRACTOR ADDRESS_ CITY/SA7VZIP _ <br /> LscENsE 13C37 ❑C-61 d D09 ether O NUMaER-:23 EKPtRAnoN DATE <br /> GEOCRAPIIICAL INFOR ION; Coordinotes X Y Township Rouge Settion <br /> y <br /> [INTENDEDUSE mcslidPrivatc D IrrigationlAgricultural 0 Industrial M Water Quality Monitoring ❑Soil Sampling/Chareacrizitumt <br /> ❑Public Water Syystem <br /> irairrereat Wm Owner'. Dear yrnm acne Mme erer- tele N.Mbe, <br /> TYPE OF WORK O NEW Well ❑Replacement Well ❑Well Alteration/Madification 13 Test Hak ❑Other <br /> ❑Monitoring Well(s) _w stnnkrofwcls ❑SoilBoring(s) numtrerarbnnngs OCoo[echnical rumberorbodnrs <br /> O Well Destruction D Out"IService Well 0 Out-OGService Well Renewal <br /> D New Pum �ep R lacetnent ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 13 Air Rorary, ❑Auger ❑Cable Tool ❑Push Poinc C]Other <br /> Proposed Well Depth ft E%CaVeLiO.l in diameter ❑Open Bottom El Gravel Pack 1 Gravel Size_!n dlamotcr <br /> C7 Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in ThickncsS/GAugdASTM Sched ❑Steel 0 Plastic ❑Stainless Steel ❑Other <br /> Grout Seat Depth R Q New Cement(941h hry,/J-ro gal water) O Sand Cement Yuct mir 17 gal water <br /> ❑Bentonite(2004 solids) ❑ManuracturerSyec%9otida % Name ❑Specson File ❑Specs Submitted <br /> Clout Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Reterdent/Accelerator(name) 09 <br /> PEDESTAL Installed By ❑Dn[IeT ❑Pump COntraetDT ❑Other <br /> Cl Co to Pedestal Dimensions: Width R lxngth_ft Thick in ❑Chrisly Box ❑Stave Pipe <br /> Pump ubmersibie O Tltrbine ❑Other HP Pump Set R Standing Wates Levet ft <br /> WELL DEITMUCT1ON ❑Open Bottom ❑Gravel Pack 0 Uncased ❑Other <br /> Well Diameter in Tula I Depth R Depth to Water R ❑Casing to be Perforated from R to R <br /> Sealing Material ❑Ncat Cement(94Th hog/S-+gal water) D Sand Cement suck mix 17 gal water 0 Bentonite Pellets <br /> 13Bentonite(20%solids) E3Manulteturar Spoc%solids__% Name ❑Specl on File D Specs Submitted n <br /> Placement Method ❑Pumped Ll Free Fall D Other_ <br /> ❑Complete with Mushroom Cap ft below grade D Complete to Existing Surface Pad <br /> I HERE T1FY THAT PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JO IN COUNTY ORDINANCES, TTi AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS r <br /> RRENT AND ACTIVE FORNIA CO CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL y <br /> t WORKERS COMP ION LAWS. I•1lT <br /> MIN M 24 HOUR REQUIRED FOR SPECTIO S-P EASE CALL(209)953-7597 <br /> ED TITLE DATE1:7--D!�f <br /> Ll 77 <br /> OwlO <br /> F FF <br /> s u <br /> By <br /> — DEPARTMENT USE N Y / <br /> iApplication Accepted 3y r., Date g . (7 Area Z Employee IDN <br /> Grout inspectitm By Date ❑ SPECIAL Well PerMit <br /> Pump Inspection By Dam }) y <br /> 13 WAIVER Received <br /> f Dcstrtufien]nspeciion By Date Constructed Well Depth R <br /> k COMM ENT'S <br /> PE SC Received hceloy/ Arosuot Ferrol <br /> Codes lafo RV RemlHed Do1e <br /> —Service Request N Invalceif Wel11Ok <br /> 3.ar Oso o C <br /> EH D 4M2-M <br /> Il16i2002 MASTER WATER WELL PERMIT <br /> I <br /> l <br />