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, 304 E WEBER AVE 3"" FL - STocKT0N CA 95202 - (209) 68-3420 ti 0 VV LEL / YU1V1Y 1'ERIV111 1 — SAN JOAQ'QN COUNTY ENYIRPINMENTAL HEALTH DEPARTMENT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED CITY/STATE/ZIP SUBCONTRACTOR ADDRESS/624 S-71/-570— LICENSE C-57 0 C-61 0 D-09 0 Other NUMBER ?-deDV EXPIRATION DATE JOB ADDRESS PHONE Y1STAT CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR NON-R c,FyNDABLE PERMIT 44'4')//%:? 41*3 W.3 Valklea-ta0 CONTRACTOR ADDRESS 07 g3 di,V/eize- /L-3c,-- SUBCONTRACTOR 4'4 fLe ApN c 9 A>e_s P tAtee(c6-- /61-1a=16q c/1 Nom: ciTyisTATEizip5 C./st p„oNt&A11-1----/c7D AVe/61,7 j 09— CITY/ZIP rirj, PARCEL SIZE /076 c (fri) Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Public Water System If different front Owner: ater Quality Monitoring 0 Soil Sampling/Characterization Contact Name or Phone Number INTENDED USE Water System Name 4 ,Air 1,Tspr '. ; c,., I/4,,An .--- r ...,Dr,M) (Li or i :I kJ -t--- //1 - 6 osti'l 'A) ...._ rry 17 II -7 0.19-4(1 e Ars rw Application Accepted By Grout Inspection Pump Inspection By Destruction Inspection By COMMENTS Constructed Well Depth P7r /44 MI — I _ r, ;. g ARTMENT USE ON Date Date Date Date Employee.ID 0 SPECIAL Well Permit 0 WAIVER Received ft c(-)0" oP,ou ibrNt 1\1._ ,\00 POC' .1‘31•0 IN :SS3HOCIV 31.I GEOGRAPDICAL INFORMATION: Coordinates X Township 3 -S4 Range Section TYPE 01; WORK 0 New Well '<Replacement Well 0 Well Alteration/Modification Monitoring Well(s) tik —frpumber of wells R 0 Well Destruction 0 New Pump 0 Pump Replacement 0 Soil Boring(s) 0 Out-Of-Service Well 0 Pumo Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary X\ tiger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth ?--6...) ft Excavation in diameter 0 Open Bottom 0 Gravel Pack / Gravel Size in diameter 0 'Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter t.,,Z., inThickness/Gauge/ASTM Sched -5 / e.) 0 Steel 9114 astic 0 Stainless Steel 0 Other Grout Seal Depth e -.,,? ft McNeat Cement (94 lb bug / 5-10 gal water) b Sand Cement suck mix I 7 gal water 0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted Grout Placement Method >/umped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) PEDESTAL Installed By XDriller 0 Pump Contractor 0 Other rAConcrete Pedestal Dimensions: Width cii-- It Length ..2, tl Thick in 0 Christy Box e*tove Pipe Punw 0 Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Llncased 0 Other Well Diameter ,? in Total Depth ft Depth to Water 575— ft 0 Casing to be Perforated from ft to ft ‘,77-3 Sealing Material *Neat Cement (94 lh bag /5-10 gal water) 0 Sand Cement sack mrt. I 7 gal water 0 Bentonite Pellets ED Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted Placement Method 0 Free Fall 0 Other ,Pumped AComplete with Mushroom Cap .3 ft below grade 0 Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITII SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO 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 TITLE 5-1"-- .5744e— SIGNED DATE PE . Codes SC Info Amount Remitted ../>'#(# t.t,ec..1_ Received By i Date Permit/ Service Request # Invoice # Well ID# ash 5-0 11777 1/4- q3Dio3 -5R06-314377 ey-77------7' 33--yee-sr_.,J _, I " /1 AC+ EHD 43-02-006 5/7/2002 cry) tvii/ 15(>7 A et-wii A-44 T ER WATER WELL PERMIT El Test Ilole 0 Other number of borings 0 Geotechnieal 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair number of borings