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WELL It PUMP PERMIT �� SAN JOAQUIN COUN'T'Y ENVIRONMENTAL IWAI:i'll I)i�,MI'MENT 304 E Wuicu AVE;3w"111,-SI'OCK'ION CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 951-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �/J �/��/,(�� 7 to ._.tp/ 7 (�/�/f/ �J/V CITY/ZIP t Z��_ > JOB ADDRESS � CROSS STREET A P N 0 ,d /O / PARCEL SIZEt/ �� V OWNER NAME1�(/�CJf-�� /��/� Z�L��rx�)!�-'S PHONE: ��yJ-�( S( OWNER ADDRESS (��7 Cl'�/h/�/ , �� CITY/STATE/ZIP 100, CONTRACTOR f/ F_ PHONE ' /� CONTRACTOR ADDRESS C CITY/STATE./ZIP —57 ` "L/ SUBCONTRACTOR PHONE: SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System II'dirferea From )wncr: nicr ysicm Name Contaci Name or Phone Numher 'I N'I'v.Or WO11K ❑New Well ❑Repincemcnl Well ❑Well Alferuliun/Mudilicaliun ❑'fest I lisle ❑tither number ul'wolle number ul bunnµs .mnnt+cr ul'bonnµv - - r ❑Monitoring Wcll(s) ❑Soil Boring(s) ❑(ic)tc _ Nell Destruction ❑Out-OI'-Service Well ElOut-Of ' is c c ❑New Pum ❑Pum Replacement ❑Pum Repair ❑Cross onnec Re it WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push P ❑Other J Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth Il Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement .ruck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level tt WELL DESTRUCTION Kopen Bottom p d Gravel Pack ❑Uncased ❑Other Well Diameter—/.a—in Total Depth it Depth to Water_ �It ❑Casing to be Perforated from Il to R Sealing Material ❑Neat Cement(94/h hug/S-l0 gal wafer) ❑Sand Cement ack ma/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids %�Nasm�e_ ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall �Jther /�-�-relf —B� "4� ❑Complete with Mushroom Cap It/below grade ❑Complete to Existing Surface Pad I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. W MI H DVANCE NOTICE REQUIRED FOR INSP CTIONS— PLEASE CALL(209)95)-76Y7 M I �. SIGNEDTITLE �� -vet DATE D O ti T AC UING( P BLIJHtHALT LI pTr DEPARTMENT USE O. Application Accepted By -r- Date d Arca Employee ID# Grout Inspection By Date ❑ S�Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Insp h nom' Dat �"-?.3 �� Constructed Well Depth ft COMMENTS PE Sc Recelved leek Amount Permit/ Codes Info It uxh Rentl(ted Dalc ticrvlcc Ret ucsl q Invoice# Well IDp EHD 43-02-006 �D _I r� f �G �� MASTER WATER WEL 1.PERMIT / 12/6/2002 q/ ,tC M^, ! .f :ai/qir j—/) �.►pn'l/�