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Joe ADDRESS —N-Arl.f--,, °---, _ \--\\.z%NC\ W N'Tb\if(NA CiTy/Zie (=1,-,N c,,c N„...-%\v. Qskt- 'altz. <br />CROSS STREET lc:\ V`V....N% '1 QV:A. APN 17 7 2 6 t") / ti PARCEL SIZE 3 oy,t-i <br />OWNER NAME N.- '9'..VNV`..\\ Si.N; N- -_...--,\... PHONE <br />OWNER ADDRESS 1--- .1k:i . t 4::, v. ,t;':11..,_k_.'"ar CITY/STATE/ZIP 4N-tZ....1 ._.....‘91,CZ\.-6..\ <br />CONTRACTOR \ <br />\'‘?‘\\W\ '.1-11,k. _ "NI 1/4.-A.. <br />ti <br /> <br />\c <br /> ''. PIMNE al6it <br />CONTRACTOR ADDRESS ,X Vs. \\.'s _ NJOBI'CWitVitc1.\\...V4... \ACa... CITY/STATE/ZIP -..S\ L.N. Q'ij caf <br /> PHONE <br />CITY/STATE/ZIP .c"\ \AN- <br />LicEttse AC-57 C-61 0 D-09 LI Other NUMBER N„;`-"-asskl.. \ EXPIRATION DATE CS:\ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br /> \\-A <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave 35t FL- - STock-roN CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />GEOGRAPHICAL INFORMATION: Coordinates X Township Range Section <br />INTENDED USE Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Charamerization <br />0 ublic Water System <br />If different rote Owner: <br /> <br />Water System Name <br /> <br />Contact Nome or Plaint Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification <br />0 Monitoring Well(s) numbe.'"wd15 0 Soil Boring(s) <br />0 Well Destruction 0 Out-Of-Service Well <br />0 Test Hole 0 Other <br /> <br />""th" b°""s' LI Geotechnical number of borings <br />0 Out-Of-Service Well Renewal <br />0 Cross-Connection Repair — ._. <br />. ..r /". . . . <br />WEI.L CONSTRUCTION <br />. _ <br /> <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool <br />Proposed Well Depth ft Excavation in diameter <br />CI Push Point 0 Other <br />0 Open Bottom 0 Gravel Pack / Gravel Size in diameter <br />-, <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (941k hag / 5-10 gal water) 0 Sand Cement sack mix 17 gal water <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor <br />0 Concrete Pedestal Dimensions: Width it Length <br />0 Other <br />ft Thick in 0 Christy Box 0 Stove Pipe <br />Pump 0 Turbine 0 Other HP Pump Set k 6% ft Standing Water Level (,.. ..,_.. ft <br />IO <br />< <br />N <br />Submersible <br />WELL DESTRUc <br /> <br />0 Open Bottom 0 Gravel Pack 0 Uncased <br />) <br />Well Diameter in Total Depth ft Depth to Water <br />0 Other <br />If 0 Casing to be Perforated from li to It <br />- <br />C <br />Sealing Material 0 Neat Cement (941k bag / 3-10 gal maw.) CI Sand Cement <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % <br />Nark mix 17 gal water 0 Bentonite Pellets <br />Name 0 Specs on File 0 Specs Submitted <br />Placement Method 0 Pumped --"'" 0 Free Fall 0 Other -- '•- ----- <br />CI Complete with Mushroom Cap If below grade 0 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 />MINIMUM 24 HOUR ADVANCE NOT! REQUIRED FOR INSPECTIONS <br />SicefFraisst1.9,Ti1111111 4--.-‘,-.2S--",... DATE \\ <br />NC! 5 2004 <br />AN JO FJ.J1 <br />LNVP <br />Oh/L:1'fI DE- <br />n <br />RFC ED k I <br /> COUNTY <br />.1ENTAL <br />IMENT <br />Application Accepted By <br />g Rife_ <br />Grout Inspection By <br />Pump Inspection <br />ll EPARTMENT USE <br />c hy <br />Date / <br />Date <br />Destruction Inspection By <br />COMMENTS eartMetial-r AfoeS-4-7 <br />Dam <br />5 /v93 %. <br />Area ,P-/ Employee IDit (q <br />0 SPECIAL Well Permit <br />o WAIVER Received <br />Constructed Well Depth It <br />--T-ZeA1 14&/exi7zi., 66)sOce <br />PE <br />Codes <br />SC <br />Info <br />Amount <br />Remitted <br />(Checidy..) Received <br />By Date Permit/ <br />Service Request If Invoice If Well ID# Cash <br />/713/ i25 -e) /7-31. iZr./-- 11/57DY- SAI21100/ 75 <br />EHD 43-02-006 <br />5/7/2002 <br />MASTER WATER WELL PERMIT