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TT L',la AJ I 1 IJITl1 1 L' &%ITAA l r—L1V ' YV•r6,�,f 7-V u • •• 4- SrxNJOAQUIN COUYrY ENVIRON,NIENTAI.HEALTH DEPARTMENT 304 E WEBER AVE 3'1,F1.6 STOCKTUN CA 95242 - (209)468.3420 NON-REFUNDABLE PERtMIT CALL. 209 953-7697 FOR I'N'SPECTIONS EXPIRES I YEAR FROM DATE ISSUED ��`u Jon ADDRESS r IP CROS:?STREET 1 � �j �a��%%� APN PAROL SIZE OWNER\AME � yr,�j�t ,,\}IQ V k`(I��n" PIIONF. OWNER ADDRESS , A z I _ CITY/S`[ATE/'LIP tONTRACTOR {_�I CT _ ��PlIO�N,En `,��,A"l`,-1,3 4 –9344 CONTRACTOR ADDrRE.SS J3 ti 1� 1} Qd�(,7*e CITY/STATE/ZIP �y��UJI s Y� iii a 1,1T J 7 SUBCONTRACTOR Sl BCOM1''I'RAC"COR ADDkE2 S ii2�5a ,QC �/�:1rt� CitT`I'!S'[AfEIZIP -A 9 LICENSE UC-57 0 C-61 O D-09 ❑Other NUMBER '1 1}510 ExPIRATION DATE GEOCRAPHICALINFORNIATION'. Coordinates X Y_ Township Rar.ge Section IN'rENDED USE ❑Domcslic/Private ❑Irrigation/.Agneultural ❑Indusinal ❑Water Quality Monitoring ;nil SamplingtCharacterizattnn O Public Water Sytem_ _ If dtffetent limm Uw,ur. Water ystcnl Nanie Comm Naint of I'[Tut r r'um r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Ahetauon/Modi6cation ❑Test Hole ❑Cther ❑Monitoring Well(s) J number of r•Clly LN�OII BUr10g(s) _ 11Oplbu of borings ❑C;mtechnical`__ numhu OClwsings ❑Well Destruction ❑Out-Ot-Service Well ❑Out-OfService'bVell Renewal ❑New Pump O Pump Reolaccment ❑Pump Repair ❑Cross-Conncciian RCpair WELL CONSTRUCTION � Drilling Method O Mud Rotury O Air Rotary MAuger ❑Cable Tool ❑Push Poin; ❑Other_ Proposed Well Depth�11 Excavation—N_ in diameter ❑Open Bottom ❑Gravel Pack;travel Size, in diameter O Conductor Casing _in diameter l Conductor Casing 1)epth fl Well Casing Diameter in Thickness/GsugeiASTM Sched_ _ ❑Steel ❑Pltsstic ❑Stainless Steel ❑Other_ Grout Seal Depth f ti 11Neat Cement(94 lh/xIg/5-10gal Nrtger) ❑Salld Cement .. _ ,tuck uric 17 gal water ❑Bentonite(20%solids) ❑Manufacture[Spec°'a solids _% Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑RetFrdant/Accelerator(name) _ PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑0(her ❑Concrete Pedestal Dimensions: Width 11 Length fl Thick in O Christy Box O Stove PIPs PUMP Q Submersible ❑Turbine ❑Other It?_ Pump Set h Standing Water Level ft WELL DmeucTioN ❑Open Bottom 13Gravcl Pack O cased O Other Well Diameter in Total Depth _ ft Dqth to Watrr li ❑Casing to be Perforated Isom ft to I't Sealing Material D Neal Cement(94 Ih hub l 5-106a!svulrr) ❑Sand CCrtcnt_ suck mi.r 17 gal water ❑Lkntonite Pellets r ❑Bentonile(20%solids) ❑Manufacturer Spec%solids _% Name Q Specs on File 13 Specs Submitted r Placement Method ❑Pumped ❑Free Fall 1�J Other 1-1 $ U, ❑Complete with Musluoonf Cap It below grade. ❑Complete to Existing Surface Pad I IIEREBY CERTIFY THAT I 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 ALM) CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS H SIGNED_ � TITLE_f �� ;Y Ir�� r�AC�y�D:VI'E � 7 C Mk ILT to r*i%164 e ulie L Fa it SK J L yo 011 DEPARTMENT USE(?NLN Application Accepted By_ Date ? Arca� Employee ID#JCS Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Insp'x[too Hy_. _ Date Constructed Well Depth ft COMMENTS ✓nl i <d�Cr !✓t'd 06t t-fJ4 'z t,04,4 t> 0/ f, PE SC Amount Received arc omit! Itrvoiceq Wc111D!i Codes Info Remltled rah R ServiceR uestq 01 oto 0 cc F..HD 43-02-006 MAS I ER WATER WFI.L PERMrr 5/7/2002