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r r LCL tea ulraa i a-+au•aa Ao 46g-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 394 E WEBER AVE 3"°FL-$TOCKTON CA 45202 - <br /> NON-REFUNDABLE PERMIT ALL 20997 Ft)R iNtirs cnoNe EXPIRES 1 YEAR FROM DA ,uED y <br /> .. _ <br /> CITVIZIF ` Y <br /> � v <br /> JOD ADDRESS - v <br /> APN O�'R3-oa <br /> PARCEL SI7-E z <br /> CSTREET <br /> ROSS �- L,(,rE�� <br /> f I'I II1Nk: r <br /> OWNER NAME <br /> OWNERADURFSS /� '�" <br /> l'I1fIN F. TUU! 1 <br /> CONTRACTOR IILI r�� <br /> CITYl$TA'I'F:1L11' 1� <br /> CONTRACTOR ADDRESS <br /> - PHONE 10 <br /> l SUBCONTRACTOR <br /> SODCONTNACPOR ADDRESS 1 <br /> E%PIRATION DA FE <br /> LICENSE ❑C-57 ❑C-A1 lD D-04 ❑Other <br /> N UMDFR <br /> Y Township Ke e <br /> GEOGRAPHICAL INFORMATION: Coordinates JC <br /> - <br /> j INTENDED USE C]DotnesticlPrivalc ❑]rrigasionlAgricuStura <br /> l ❑industrial ❑Water Qua Monitoring ❑ i Sar a leriza <br /> If ❑Public Water System <br /> 1rdimmm anoau �m�or <br /> f from -.r: amt ys[em arm <br /> lnwnbcs of 6arinys <br /> EI l l <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well ASlemlionlModifrca6on nun1 p o s I'bore ❑0 Other <br /> huical <br /> nant6er orwclls ❑Soil Boring(s) <br /> ❑Monitoring Well(S) r <br /> ❑Well Destruction �Oul-Of-Service Well ❑Gut-01=Service Well Renewal <br /> esr <br />+ 0Cross-Connection Repair <br />!`k ❑New Pum ❑Pum R lacement ❑Pum Repair <br /> WELL CONSTRUCTION ❑Push Point ❑Other J <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool in diameter _ <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom 6 Gravel Pack!Gravel Sipe ` <br /> p Conductor Casing <br /> in diameter / Conductor Casing Depth II h <br /> ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> h <br /> j Well Casing Diameter_in Thickness/Gauge/ASTM Schad �— ❑Band Cement stick miv l7 gal water � - <br /> i Grout Seal Depth kl ❑Neat Cement(94 Ih hag/5-10 gal warer) ❑Specs on File ❑Specs Submitted <br /> ❑Bentonite(20%solids) L]Manufacturer Spec%solids % Name <br /> Grout Placement Method [I Pumped ❑Free Fall ❑Other <br /> ❑Retardant 1 Accelerator(name) <br /> ❑Driller Q Pump Contractor ❑Other <br /> PEDESTAL <br /> Installed� in ❑Christy Box [I Stove Pipe <br /> ❑Concrete Pedestal Dimensions: Width It Length-11 Thick 11 <br /> ❑Turbine ❑Other Hp Pump Sol It Standing Water Level <br /> PUMP ❑Submersible <br /> ` ❑Open Bottom D Gravel Pack ❑Urscased ❑Other <br /> ! WELL DESTRULTIDN i; P f[ ❑Casio to be Perforated 1-tom ft m R <br /> Well Diameter—in Total Depth It Depth to Water g <br /> Sealing Material , ❑Neat Cement(94!h hug/5-JO gut waren) 13 Sand Cement stick mix!7 gal water ❑Bentonite Pellets <br /> r ❑Specs on Fiic ❑Specs Suhmitted <br /> ❑Bentonite(2i1%solids) ❑Manufacturer Spec%solids_% Name <br /> placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Cam Tete to Existing Surface Pad - <br /> ❑Complete with Mushroom Cap A below grade P <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITSTATE LAWS, AND RULES AND REGULATIONS. I H SAN <br /> I ORRRE T AND ACTIVE(WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARDALSND TCERTHAT 1 AMTHAT <br /> IN COMMY RPLIANCEUIRED LW ICENSEALL <br /> IS <br /> WORKERS COM PENSATION LAWS. <br /> MINI 7 24. OU ANCE NOTICE REQUIRED FOR INSPECTIONS �3 <br /> TITLE DATE <br /> SIGNED <br /> t <br /> r., <br /> c <br /> 4 - <br /> A <br /> I _ <br /> I <br /> _ EPARTMENT USE �1' <br /> ;' -cl-0ate Q Arca Employee IDN C� <br /> Application Accepted By -I ! <br /> k Grout Inspection By <br /> Dale ❑ SP CIAL Well Permit <br /> Pump inspection By <br /> Date ❑ \ RIVER Receiveff/ <br /> Date <br /> ConMructed Well Depth c "-`'-"•-- -•�_ <br /> Destruction Insp ion By <br /> TS <br /> yOMMEN <br /> PE Received Dale Permit/ Invoice# �Vcll Il)# <br /> SC Amount - +•'_�.,,! <br /> Codes info g Remitted Cash By Service Re ucslN <br /> •i�, �-»>�' ��C1�-- -e--ate � MASTER WATER W LLL PERMIT <br /> MID 43.02-006' <br /> � 51712002 �' <br />