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WELL 1 PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTH DEPARTMENT 304E WEBER AVE 3"FL- STOCKTON CA 95202 - (2119)468-3420 <br />NON-REFUNDABLE PERMIT CALL (289) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�! rn <br />JOB ADDRESS t Z A (r Ai i G'ryY/ZIP-[ _ $ L'Y-C>—� / <br />sal a <br />/^� r v <br />CROSS STAEET ,/ tirJ\/. �,� .•r ,l APN C' J I3at�n GG PARCELSIZE <br />OWNER NAME �iOG PHONE'114- �'3-4 <br />OWNER ADDRESS IZ 2}'67 L D/14 /-tof 7 / Crry/S`TATEIZIP r)q Cj <br />CONTRACTOR Al C -- D, /9 rja 6riSall,J -L G� 4? 4;74- <br />A!:5,e!§• <br />PHONE 7 3 Z ���vyJ <br />CONTRACTOR ADDRESS Z r -"r dV § 7'7',11#1(• CEEY/SYATE/ZIP C� dj1 7 Zj <br />SUBCONTRACTOR PHONE <br />SUBCONTRAr_-TOR ADDRESS try CITY/STATEIZIP <br />E3 C-61_ f <br />LICENSE C-57 bl 11 D-09 0 Other/, '1 NUMBER EXPIRATION DATE v <br />GEOGRAPHICAL INFORMATION: Coordinates X V Township Ranee. Section <br />INTENDEDUSE ❑ Domestic/Private Olrrigation/Agricultural ❑ Industrial O Water Quality Monitoring Soil Sampling/Characterization <br />0 Public Water System <br />Hditrerenr from Owner Warcr Nyv.. Nam aaled emeer one Number <br />s era vv AOKK u iNew wen u Keptacemem wen u well AtterattonModification ❑ Test Hole 13 Ocher <br />❑ monitoring Well(s) wmberofwella 4SoilBoring(s) $_— numbernfbodnys 0Gemeehnical number oftwrino <br />Well Destruction p putt -Of -Ser ice Well ❑ Out -Of -Service Well Renewal <br />WELL CONSTRUMON <br />Drilling Method 0 Mud Rotarry+- ❑ Air Rotary Auger 0 Cable Tool EI Push Point 13 Other <br />Proposed /Veil Depth? ft Excavalical A in diameter <br />❑ Open Bottom d Gravel Pack/ Grovel Size in diameter <br />O Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in ThicknesstGaugeASTM Schell <br />0 Steel ❑ Plastic 0 Stainless Steel 0 Other_ <br />Grout Seal Depthr # AJIZY ft ❑ Neat Cement (94 Ib bag / 3-10 got water) <br />_ <br />Q Sand Cement ,vack mit / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spa % solids is <br />Name )/ 4zo-rr')/-/0 ❑ S ccs on File 0 Specs pees Submitted <br />Grout Placement Method ❑ Pumped D Free Fall O Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Instilled By ❑ Drille u Contractor <br />❑ Other <br />O . <br />Concrete Pedeaul Dime ora f R Length_ <br />ft Thick in ❑ Christy Box O Stove Pipe <br />PUMP ❑ Stlhmeraible ❑ Turbine O Other HP <br />Pump Set it Standing Water Level ft <br />WELL DESTRUcrioN 0 Open Bottom ❑ Gravel Pack ❑ Uncased <br />O Other <br />Well Diameter in Total Depth ft Depth to Water <br />ft 0 Casing to be PerY-front ft to ti <br />Sealing bfaterfal ❑ Neat Cement (94 h5 bag /5-10 gat water) 0 Sated Cement <br />sacknrtr l7 gal watrte0 <br />- <br />Bentonite (20solids) ❑ Manufacturer Spec % solids % <br />Name cso n File ❑ Specs Submitted <br />Placement Method ❑ Pumpcd O Free Fall 0 Other <br />❑ Complete with Mushroom Cap ft below grade <br />❑ Complete to Existing Surface Pad <br />I "EKZUx eEKIJrT IHAI I tIAvL YKLrARLD -THIS AYYLICATIUN 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 MV REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />1VORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADW E ftHetMRED FOR INSPECTIONS - PLEASE CALL (209) 953-76497 <br />SIGNED TITLE _ DATE 17--+ <br />L� <br />'0 <br />I I Ilk I 4Ae <br />11 1 1 AX <br />I - <br />I M tml <br />i - <br />Application Accepted By <br />Grout inspection By <br />Pump01-- <br />Destruction <br />COMMENTS <br />SC <br />Info <br />EHD43-02-006 / <br />12!6/2002 <br />Date <br />Nlate <br />E)a a�am� <br />71 <br />Areah �-1. I 'J� Employee ID# �41_ _ <br />Q SPECIAL Well Permit '7 Off <br />❑ WAIVER Received <br />- Constructed Well Depth It <br />�M <br />I11voice# l Well ID# <br />