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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 307 E WEBER AVE 3"°FL-STOCKTON CA 95202-(209)46$3420 <br /> NON-REFUNDABLE PERJMIIT/ CALL 209 953-7697 FOR INSPECTIONS EEXXPIIR/E�S�I YEAR FROM DATE�`ISSUED <br /> JOBADDRESS `r ,l.{p 1/ � 2�j CITYIZIP 1�vtiM \�j - ( �3 L�p � <br /> CROSS STREET GYLGIY7M 1y� APN -�O((�D D9 r <br /> f_11 <br /> /� +�J l �J' PARCEL SIZE <br /> OWNER NAME S.�/��1.(��t(.tl}f� fL <br /> OWNER ADDRESS �/•i}1� �.` ����� 1! Crl'Y/STATFlLIP <br /> O <br /> CONTRACTOR �� PHONE <br /> CONTRACTOR ADDRESS C"ISTATE..1 A'5 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATFILIP <br /> LICENSE O C-57 O C-61 ❑D-09 her R <br /> EXPIH.ITiON DATEPEQ 3 <br /> GEOCRAPHICALINFORMATION: Coordinates X Y <br /> Township Range Section__ 7 <br /> InTENDEn USE mesWate Sys 0i ❑Industria! ❑Waur Quality btonilonng C Soil Sampling/Charaacrization <br /> ❑Public Water System <br /> lfdiffcmi from Owner.----Caror rr+em,ame -- <br /> .anuu arae a nc.um•r <br /> TYPE OF WORK ❑Ncw Well O Replacement Well O Well Alteration/Modification O Tcs(Hole ❑Other <br /> ❑Monitoring Well(.,) Dumber ofweuc <br /> O Well Detmcton C]Soil Boriag(S) y OGeotechn—ical— nunnt—fbtnjp <br /> Out-06Service <br /> `f <br /> Well O Out-0R-Service Well Renewat ' <br /> O New Pum ❑pum R lacement mo <br /> CONSTR£ R air ❑Cruss-Connection Repair <br /> CTION <br /> Drilling Method C2 Mud Rotary ❑Air Rotary ❑Auger O Cabk 7-col ❑Push Point ❑Other <br /> Proposed Well Depth <br /> WELL <br /> f: Excavation diameter ❑ <br /> Open Bottom O Gavel Pack/Gavel Siu in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 0 <br /> Well Caving Diameter-Le in Thickness/Gauge/ASTM Sched,__ _ %.Stecl O Plastic O Staiolm Steel ❑Other <br /> Cmut Seal Depth h ❑Neu Cement(94/h h99/5.10 gai w ler) ❑Sand Cement suck mer 17 gal water <br /> ❑Bentonite(20%solids) CI Manufacture'Spec%solids_% Name_ O Specs on Pile O Specs Submitted <br /> Grout Placement Method fl Pumped O Free Fall O Other ❑Reterdam/Accelerator(narne) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contactor ❑Other _ <br /> O Concrete Pedestal Dimensions: Width_it Lmgth_R Thick in ❑Christy Box O Stove S— it 13PUMP Submersible Turbine O Other HP Pump Set ft Standing Water Levc1---L (t <br /> WELLDESTRuenoN ❑Open Bottom ❑Gavel Pack fl Uncased ❑Other <br /> Wcll Diameter_in Total Depah tt Depth to Warer "R ❑Casing to be Perforated from ft to it <br /> Sealing Material ❑Neat Cement(94 lh bog/S-)Opal wafer) ❑Sand Cement sunk—/7 gal water O Bentonite Pillets <br /> ❑Bentonite(20%solids) O Manufac(ura Spec%solids % Name ❑Specs on File O Specs Submitted <br /> Placement Method O Pumped O Frce Fall O Other _ <br /> ❑Complete with Mushroom Cap. ft below gradeO Complete m L•xisting Surl'acc Pad I <br /> 1 HEREBY CERTIFY THAT 1 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 /> N1MUM 24 HOUR ADVANCE NOTICE EQUIRFD FOR INSPECTIONS <br /> SIGNED .r• - f� n'/ <br /> TITLE DATE <br /> i <br /> r t—_ <br /> I <br /> SA -'(A .N" <br /> ,iLi HE FR IEE: <br /> /1i n ,()_ � � DEPART1v1ENT'U/SE , >, <br /> Application Accepted By IAA),.0 �Ilt,lJv _ - Date l/-d OZ� Area Employ«IDN,-�. <br /> Grout Inspxtion By - , <br /> Date 13SP£elI L WeIIYFTyiC_-'— <br /> Pump Inspxtion Date !/ �___,__ ❑ WAIVER Received <br /> Destruction Inspection By DateConstructed Well Depth <br /> COMMENTS - ft <br /> PE SC Amount tt Received Permit/ - -- <br /> odw Info ( Remlrted ac BY D°1 voiceN Wd11D# <br /> 3 �j C� / <br /> Service uesti <br /> J u - <br /> I - <br /> EHD 43-02-006 / <br /> 5/7/2002 / MASTER WATER WELL PC•RMIT <br />