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11}ALL/ 1 V 3111 1 a�l�llAa a ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMEN'r 304 E WEBER AVE 3`°FI.•STOCKTONg- 20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPFCTIO14S EXPIRES 1 YEAR i� UED <br /> Lib� Mao.ram <br /> 2 f any tj <br /> t �I y <br /> JOBADDRES.S /'1"� AU o _ nCrrV1ZIPp� <br /> CROSS STREET ,IJ�r �7/��UU.1 J 1 APN�9�7 L7�JGiS //P�ARCEfL SITE 1 /�..✓ 7� <br /> OWN ER NAME /rC//�M1�c�f-1L " ii op CA!� PIIUNE h J <br /> OWNERAUDRESS I CITY/STATF/ZIP <br /> CONTRACTOR .r QS C �!�G IIS__ PHONE ' / r--✓ <br /> CONTRACrORADORESSS, _��V /� CITYISTATE/ZIP a&VA4 p �C <br /> SUBCONTRACTES <br /> OR ��.'�r! _ �{/YS�Y PHONE <br /> SUBCONTRACTOR ADDRESS ��— CI'rY/S-T�ATFJZIP a �J�'✓ _ <br /> LICENSE -57 0 C-61 0 U-09 0 Other NUMBER 377.385 EXPIRATION DATE <br /> GF.OGRAPHI CAL INFORMATION: Coordinate! X Y Township_ Range Section <br /> lNTT.A'DED USE -i9t13amestie/P0vate O lrrrgation/Agricultuml O lndustrial 0 Water Quality Monitoring 0 Soil Sampliag/Chatacterization <br /> (] Water W <br /> Public System <br /> If allic Water Owner ser yaam arra - onuetName or na Wni / <br /> TYPE OF WORK New Well 13 Replacement Well 0 Well AherauonfModiftc:allon 0 Test Hole O Other <br /> numtxr orwdls nurnkr of borinpn nurnbcr of Dnrinxs <br /> D Monitoring Wells)_ Q Sud Borings) D Geotechnical <br /> 0 Well Destruction 0 Out-Of-Service Well 0 Out-Of-Servire Well Renewal <br /> Q ew Pum 0 Pum Replacement 0 Purrmip Repair 0 Cross-Connection Repair <br /> WELL CONSTRU 'I <br /> Drilling MethndR Mud Rotary 0 Air Rosary Q Auger 0 Cable Tool Q Push Point 0 Other <br /> Proposed Well Depth Z M ft Excavation in diameter 0 Open Bottom Gravel Pack 1 Gravcl Size in diameter <br /> 0 Conductor Casing in diameter / C� n <br /> onduc�m�r Cos' Depth Il <br /> Well Casing Diameter-C--in Thiekness/GL <br /> auge/ASTM Sched . 0 Steel .;�"lasuc 0 Stainless Steel 0 Other <br /> Grout Seal Depth:L 150—ft .W Neat Cement(94 lb berg/5-10gar wafer) wand Cemcnt ^J .yuck mer/7 gal water <br /> ❑Bentonite(20%solids) 0 Manut'acturer Spec%solids Yo Name_ O Specs on File 0 Specs Submitted <br /> Grout Placement Method umped Q Free Fall 0 Ober 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed av <Driller 0 Pun:p Contractor k� ❑Other <br /> Cl Concrete Pedestal Dimensions: Width— fi Length C R Thick in 0 Chrlsty Box 0 Stove Pipe <br /> PUMP .-Awitbmersible Q Turbine 00ther HP_� Pump Set h Standing Water Lcvel II. <br /> WELL DESTRUCTION 0 Open Bottom Q Gravel Pack 0 Uncased 0 Other <br /> Well Diameter_in Total Depth It Depth to Waicr B 0 Casing to be Perforated from ft to R <br /> Sealing Material 0 Neat Cement(94/h berg/5-10 gab Water) C Sand Cement sat-h nrix 17 gal water 0 Sentonite Pellets <br /> 0 Bentonite(201/6 solids) 0 Manufacturer Spec°/solids__% Name 0 Specs on File 0 Specs Submitted <br /> Placement Method 0 Pumped 0 Free Fall - 0 Ocher <br /> O Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad <br /> I 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 /> N NIMUM 24 HOUR ADVANCE NOTIC/E�REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> Uee <br /> r <br /> � I.V <br /> w <br /> DEPARTMENT US ON _ <br /> Application Accepted By _ Datr d L Area 2-� 2 Employee IDN <br /> Grout Inspecti0r.By Datc z ❑ SPECIAL.Well Permit <br /> Pump Inspection Ry __ Date - 0 WAIVER Received <br /> Destruction Inspection By— llate Constructed Well Depth` ft <br /> COMMENTS 17.6 U r <br /> — <br /> PE SC Astfount Recelved Permit/ <br /> Codes Info Remitted B Date Service Request N Invoice N Well IDN <br /> X80 oS-d S7J ©0S ,,rt d Llllt� <br /> El ID 43.02-006 MASTER WATER WELL PERMIT <br /> 3)78002 <br />