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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVTRONMENT TH DEPARTMENT 304 E WEBER AVETocicroN CA 95202-(209)468-3420 NON-REFUNDABLE PERMI CALL,(209) 953-7697 FOR INSPECTIONS EXPTI YEAR FROM DATE ISSUED JOBADDRESS r�1�1. � �. %�N�!t �(� P\C-' A t I, � CITY/ZIP k 1ytp. i.)C' iV K c/i 30 > CROSSSTREET ! `APN - "' - �.PASCIL SIZE '- LAND USE APPLICATION# P LTE 4Z 1�Ci I c,r7l i' 1 PHONE)GC (,> Jt L62 y OWNER NnMe OWNER ADDRESS l!` C1-ti / /�1 ST C' CITY/STATE/ZIP 1 V ''�' /�J'l. .fi CJ��,t CONTRACTOR ��C�.(�l I`ILI,L� IZ C%CN 11�.� C N ICGL L PH(ONE�L.%{ - ! /J )- -�s 7L/ CONTRACTOR ADDRESS I C! /1 Ci IZ( .l 1 f Ci C,l CITY/STATF/ZIP\," J" I 1 5 C-A SuacoNrRncroRCDll I l tC7= i? C ANCt1>j.<, .� /�f __ PHONE aC�j• �J.�j SUBCONTRACTOR ADDRESS/_/l q z//o l y jZ� C-N_� CITY/STATE/ZIP`F S C(-) I P,Yy l A LICENSE C-57 E3 C-61 0 D-09 0 Other NUMBER J EXPHLAT10N DATE , GEOGRAPHICAL INFORMATION: Coordinates X 1,3 L-,.]'7 Lt) v-3 114. !t'} r T Township Range Section INTENDED USE O Domestic/Private 0 Imgation/Agricultural 0 Industrial 7watbr Quality Monitoring Soil Sampling/Characterization 0 Public Water System VdilTerem t m Ow"ee Winer System Name Contact Name or Phone Number t TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Altemtion/Modif.:ation 0 Test Hole 0 Other O Monitoring Well(s) =ofwelis 3TSoil Boring(s) )4s 0Geotechnical ttOI hUO" hA,` 0 Well Destruction 0 Out-Of-Service Wei! 0 Out-OC-Service Well Renewal C� 0 New Pump 0 Pump Replacement Cl Pump Repair 0 Cross-Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Taol Push Point 0 Other Proposed Well Depth 3�Z-' ft Excavation_y in diameter ;a Open Bottom 0 Gravel Pack/Gravel Size in diameter t tt ❑Conductor Casing in diameter / Conductor Casing Depth 11 Well Casing Diameter in Thickness Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other Grout Seal Depth 7r) 0 r Neat Cement(94/b bag/5-10 gal„osn 0 Sand Cement sack mix/7 gal water 1� 0 Bentonite(20%solids) 0 Manufacturer Spec%solids Name ❑Specs on File 0 Specs Submitted J Grout Placement Method 0 Pumped 0 Free Fall ;eOther �f�-YA3.{Q 0 Retardant/Accelerator(name) PEDESTAL Installed By 0 Dnller 0 Pump Contractor 0 Other 0 Concrete Pedestal Dimensions: Width R Length-11 Thick in 0 Christy Box 0 Stove Pipe Pump 0 Submcmible 0 Turbinc 0 Other - Pump Sct ft Standing Water Level Il WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncase.i Other Well Diameter__in Total Depth R Depth to%tater ❑Casing to be Perforated from _0 to_ fl Sealing Material 0Neat Cement(94/b bag 15-10 gal water) 0 Sand Cemc-: sack mLr/7 gal water 0 Bentonite Pellets 0 Bentonite(20%solids) 0 Manufacturer Spec%solids Name 0 Specs on File 0 Specs Submitted Placement Method 0 Pumped 0 Free Fall 0 other 'TrQ M'e 0 Complete with Mushroom Cap R below grade 0 Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 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 1 AM IN COMPLIANCE WITH ALL "w.. WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SlGNED---P1 TITLE i�_A- I�I.f.{ DATE I I I I CCUO AR MENS RTMENT U Application Accepted By 9 DEPAN Date Area Employee tD# Grout Inspection By Dale 0 SPECIAL Well Permit Pump Inspection By Date 0 WAIVER Received Destruction Inspection By ` Date O¢ Constructed Well Depth R COMMENTS Fcllt,� b� �t..t- las- ,T Q(Olwt.? LQntrRnn,� PE SC Received Cheek#/ Amount Date PermW Invoke# Well ID# odes Inf B Remitted ServiceRequest# ®y 159. 113- EI In 43 0240, MASTER WATER WELL PE RM 1"r.d,k 12/22/2013