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WEL' 'UMP PERMIT WWI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEA1.111 DEPARTMENT s,san f, 304 E WEnEit AvE 3a"FI.-ST(X'KTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 I:OR INSPEf-TIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 34'W 7 �7/L-L/'�i/i cZl/✓ C11Y/LIP �//�-/y r ��T!� .a`�, <br /> /Vi�W TCJ� / /O J <br /> CROSS STREET APN l.'�(7r !� / / PA/NJ('t:l?.til%k'. �e?i^1 <br /> OWNER NAME f!/!-fid S f /?�L1Y,Y)�_S PHONE <br /> OWNERADDRESS U /1 --AtT�Z0 -� &2Q CITY/STATE/ZIP n km <br /> CONTRACTOR f/ t PIIIoN�4:,��L' <br /> CONTRACTOR ADDRESS /-�Q_C CITY/STATE/ZIP <br /> SUBCONTRACTOR d!//y PHONE <br /> SUBCONTRACTOR ADDRESS �� CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER E%PIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private O Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampl i ng/Chamcteri za lion <br /> ❑Public Water System <br /> Ifd f—,from OwnerWaver System ame Comact ame or Phone Numtnr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ,{❑,,�M'onitoring Well(s) numberof-lis 0Soil Boring(s) -mberoftmorp ❑Geotechnical number of borings �- r <br /> y�/w ell Destruction O Out-OfWell ❑Out-Of-Service Well Renewal <br /> /❑New Pump ❑Pump Replacement ❑Pump Repair O Cross-Connection Repair <br /> WELL CONSTRUCTION - (� <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V J <br /> Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth Il <br /> Well Casing D1aincicr_in Thlckncss/Gaug✓ASTM Sched ❑Steel ❑Plastic ❑SlallllCSx Steel ❑Other <br /> Grout Seal Depth 11 ❑Neat Cement(94 lh hug/5-10 gal wafer) ❑Sand Cement suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ fl Length_tl Thick in ❑Christy Box O Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set it Standing Water Level Il <br /> WELL DESTRUCTION XOPcn Bottom o d Gravel Pack O Uncased O Other <br /> Well Diameter-4/0-in Total Depth fl Depth to WaterB C3Casing to be Pertorated from 11 to it <br /> Scaling Material O Neat Cement(94lh hug/3-10gal w er) ❑Sand Cement­0(4AZL-!!5;vack mir/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20a/solids) O Manufacturer Spec%solids �%.,a Name ❑Specs on File ❑Specs Submitted <br /> Placement Method O Pumped ❑Free Fall �ther 7�e'�(� <br /> ❑Complete with Mushroom Cap Il elow grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI�y 11MI -VANCE NOTICE REQUIRED FOR INSPr 7f,("NONS-PLEASE CALL(209)95 -76SIGNED 1'/ r�� TITLE ^tic-e DATE <br /> 1 <br /> AC IN <br /> BL11 tit 1N AI T 11 <br /> DEPARTMENT USE <br /> Application Accepted By Dale ` Area Employee ID#J! ./'f / _e� <br /> Grout Inspection By Du tc ❑ SPE:IAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> i <br /> Iksbruclion Insp h n ��'-' Dut ��,� /`�� " 7-�Constructed Well Depth ft <br /> COMMENTS - _�J(J/rLF� 1111, <br /> PE SC Received eck# Amount Perini(/ <br /> Codes Info B Cash Remitted Dale Service Request# Involee# Wel-11 D# <br /> /.$-0 <br /> f:IID 41.02.006/_-X '�7��/, ffgr�t•�-.G•� ! yC'f�r. �/� 9Qn�,tr ..A.r/I�A f f f /(i Gil M,f, MASTER WATT H WEIl1.PERMIT <br />