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WELL/PUMP PERMIT <br /> SAN JOAQVIN COUNT%'ENVtRONMENTAL HEALTR DEPARTMENT 304 E WFBRR AVE.3"'FI.-STM:KTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AUUR£SS '3 / k <br /> 0 <br /> 0 <br /> CROSSSTRE£T r✓t/Y Y"a APN �'t- t "� PARCEL SIZE Am <br /> - <br /> OWNER NwMr°. toC G P <br /> OWNER ADDRESS CITY/STATFIZIP <br /> ---1 PHONE <br /> I; CUNTRACI'OR <br /> CONTRACTOR ADDRESR / CITYISTATFI•LIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTORADDRMS q CITYISI'ATE/T.IP <br /> LICENSE ❑C-57 OC-61 ❑D-09Othe .Z NUMBER _ EXP RATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Sec Hon <br /> INTENDED USE 72DChtestic/Private 0 trrigarion/Agricultutal ❑Industrial ❑Water Quality Muniwring O Sol Sampling/Chatacttrirrtion <br /> 0 Public Water System ---- - - -- --t-unir:i�c ui Phone Nuni6<r - <br /> lfdiffe—fmm Owner seer yslem.nix <br /> TVPF.OF WORK O New Well 0 Replacement Well 0 Well Alwration/Moditicauon D Test Hole 0Other _ <br /> number of wills numbn ui'borings number of borings <br /> I ❑Monitoring Wells) _ ❑Soil Borings) ❑Geoixhnical <br /> 0 Well Destruction 0 Out-OfService Wcll 0 Out-of-Service Well Renewal <br /> 0 New Pump 0 Pump Repla::ement [3 Pump Repair ]NQ:rOSs-Cumieclion Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Kotay 0 A-uger 0 Cable Tool 0 Push Point O Other <br /> Proposed Well Depth__ 1*1 Excavation in diameter O Open HOItDm 0 Gravel Pack/Gravel Sizc in diameter ` <br /> 0 Conductor Casing in d:ameter / Conductor Casing Depth — -A <br /> It <br /> Well Casing Dia-eter_in ThicknCSS Gaug✓ASTM Schad 0 Steel 0 Plastic 0 Stainless Sreel 0 Other W <br /> Grout Seal Depth It 0 Neat Content 1,94 lb hagl5-1 ogal water) 0 Sand Cement _.. _sack mix 17 gat water <br /> 0 Hentnnite(211%solids) 0 MBnnIACIUTer Spec%solids_% Nance_ 0 Specs on Filc 0 Specs Submincd <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) _ - <br /> PEDESTAL Installed By 0 Driller 0 Pump Con tracior 00ther--- <br /> EI Concrete Pedestal Dimensions: Width_9 Lengih ti Thick In 0 Christy Boa 0 Stove Pipe <br /> Pump �fiil�cubmersible 0 Turbine ❑Other HPPumpScL_,(e 3 ti Standing Water Level tl <br /> WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br /> Well Diameter in Total Depth It Depth to Water It ❑Casing to be Perforated from 11 to ft <br /> Sealing Material 0 Neat Cement(94 111 h09/5.10bW/arorer) 0 Sand Cement xuck mix/7 gal water O Bentonite Pellets <br /> 0 Bentonite(2(r/a solids) 0 Manufacturer Spec%solids T_% Name 0 Specs on File 0 Specs Submitted <br /> Placement Method 0 Pumped Q Free Fall 0 Other <br /> 0 Complete with Mushroom Cap • ____it 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 7 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RALES AND REGULATIONS. I ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL h <br /> WORKERS COMPENSATION LAWS. �# <br /> V U <br /> UR ADVANCE NOTICE REQUIRED FOR IN PFCTIONS—PLEASE CALL(209)953^-]7697 <br /> SIGNED j TITLE 2 D.T. <br /> IF r <br /> r <br /> FT <br /> 44 <br /> I <br /> rl <br /> i <br /> AN JO kOt"IN N <br /> i <br /> DEPARTMENT USE N V <br /> Application Accepted By — - ��_ _ Date :F Arca Z t fo Employee ID# 456' <br /> Grout Inspection By _ Date 0 SPECIAL Well Permit <br /> Pump lnsprztion By ti f+"r-c_ nate �1Z' D`>/ O WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ,_ ft <br /> COMMENTS <br /> PE SC I Received Ch Amount Permit/ <br /> Codes Info B Cash Remltfed Date Service Re uest# lnrvoicc# Well IDk' <br /> '45 -7'7 f C F;-c !17P SZ tzJ 5- `3g <br /> EHD43-02-006 <br /> 12/6/2002 MASTER WATER WELL PERMIT <br />