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1,0frpk. Ca. <br /> fat-iset <br />to rjj :ce <br />0 C._ 1 <br /> <br />wir <br />••••••••••• <br />0114-0--. <br /> <br />0 <br />DEPARTMENT US)./E ON, <br />Date <br />Date_ <br />Dale <br />-.0,•••••-••••••••,... <br />1 <br />Arta Lott, oyer IDtr <br />SPECIAL Well Ptrrnit <br />WAIVER Rtoccived <br />Constructed Well 1)epth ft <br />3:11S" <br /> a <br />WELL, /PUMP PERNIIT .."" • <br />SAN /paws COUNTY ENvIRONRENTAL HEALTH DEPARTMENT 304 E WEBER AYE V"' FL- SrocKTON CA 95202 - (2119) 4(8-3410 <br />NON-REFUNDABLE PERMIT <br /> CALL (209) 953-7697 FOR INNFECTtoNs EXPIRES 1 YEAR FROM DATE ISSVED <br />NA'? J08 AMMER> ..500 M Tot! <br />CROSS STREET (?;1." JO i gr <br />°Wink NAME <br /> I. a PI 0 <br />OwNER ADDRESS 0 • dr, ( "ecrui <br />CONTRACTOR ifrierre-gs 217 <br />CONTRACTOR AVOWS Atbe vr dr <br /> PARCELSILL 110. t <br />PHONE 'PA" a <br />CDT/STATULtr <br />CrrWSTA maw nt le:'S....40 r <br />SUBCONTRACTOR . PHONE <br />SHOCOPaRACTOR A omtESs <br /> CITT/StATErLIP <br />LICENSE XC-57 C-61 0 19.09 0 Other <br /> POWDER keReAer EXPIRATION DATVail <br />GloGRAPHIC AL INFORMATION: COOrdinates X Township , PhEC .Section <br />,rrartENDED USE 0 Domestic/Private 0 lgation/Agricultural 0 Industrial U water Quality Monitoring 0 Soil Ss mplingiCha tacterinition <br />1101 Public; Water System f‘ri . t.tx, <br />ei trere,si nes, (Nssair ater UM sane C 5 -kt/ 5 6 <br /> <br />C /Ze, <br />onmcC.Nennneat Number P <br />0 Replacement Well 0 Weil AltcratikrnModificatiac 0 Test Hole C/Wr Aub,,,,,,r wino <br />nonemrer west o soil uorines) noreeraibmaW <br />Well lkstruction 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal <br />keolucerneirt 0 Pump Repmr 0 Cross-C,'unniNucn Repair <br />TYPE Or WORK C New Well <br />0 Monitoring Well(s) <br />.1.1 CORLCTLtJN <br />Drilling Method I. Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />, Aro <br />Proposed Welt Depth „zoo ft Excavation_ / in diameter 0 Open Bottom *avel Pack "Gravel Sire in diainelet <br />CI Conduct2.4,915 in diameter r Conductor Casing Depth. il <br />Well Casing Dtarneter K.... in Thickness/Cauge/ASTM Sened 47019___ 0 Steel .Plastic 0 StailliaS Steel 1:2 Other <br />Groin Sea/ Depth 49_ tt LI Neat Cernent 614 1h hag / .5.II, Ix& water) yrsand Cement / 6 , 3 gra mix 1 7 gal water <br />409ntraMj-(414111idOw- a Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted a <br />Grout Placement hIethod )Sr,romped 0 Free Fall 0 Other 0 Retardant I AccelereaN (name) <br />felEllESTAL Installed By 0 Driller >26.,....tunp Contractor 0 Other <br />)(Concrete Pedestal Dimessions: Width_ 1 ft Length < ft Thick _ ial in 0 Christy Box 0 Stove Pipe ,--. <br />Pumr 0 Submersible 0 Turbine 0 Other HP Pump SO ft Standing Water Level 11 <br />WELL OT crlws 0 Open °Worn 0 Gravel Pack 0 Unused 0 Other <br />Well Diameter in Total Depth tt Depth to Water ft 0 Ca:tingle be Perforated iturst It to ft <br />Sea ling NI aterial 0 Neat Cement ON 1h 'mg , 5- I ago/ wirier) 0 Sand Cement wick ode 17 gal water 0 Dentnnite l'ellet$ <br />t:i Bentonite (20% solids) 0 Monatomic= Spec % solids % Name 0 Specs on Hie 13 Specs Submitted ,...., <br />Placement Method 0 Pumped ' - 0 Free Felt C 011scr <br />0 Complete wtth Mushmoin Cap II below grade 0 Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I IlAvE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE L.AWSS AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH Tilt CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE will ALL <br />WORKERS COMPENSATION LAWS. <br />MINT/124 HOUR ADVANCE NOTICE RFRUIRED FOR INSPECTIONS <br />SIGNED ; rYt. T rr k DATE <br />P•••••••-• <br />raky\*N1 <br />M GE En <br />/414 NtoC(173 <br />Applicanon Acceptq.Ry <br /> <br />Grout Inspection By <br /> <br />Pump laspectron By <br /> <br />Ocsirucooss Inspection By <br />COMMENTS <br />Eti3 tzgn <br />PE <br />Codes <br />SC <br />info <br />Amount <br />Remitted <br />,..‹e p Received <br />B Date Permit/ <br />Service ReqUESt a invoke A Well IDS <br />11510S 1 .45' i 3 4,4 — 1,21- 6 7 10'5 51Z003457 I Da7 Pc' <br />Eli° 43.02406 mAs ER WATER WELL PERMIT <br />snizoo2