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INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural <br />0 Public Water System <br />If different from Owner: <br />0 Industrial JETWater Quality Monitoring Soil Sampling/Characterization <br />Contact Name or Phone Number Water System Name <br />DEPARTMENT US <br />Application Accepted By '171 <br />Mk. I flW.2 Grout Inspection By ,01140,. <br />Pump Inspection By <br />Destruction Inspection By <br />COMMENTS <br />Date <br />Date <br />Date <br />Date <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEM .ARTMENT 304 E WEBER AVE 3"" F ;KTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br /> CALL (209) 953-7697 FOR INSPECTIONS EXPIRL YEAR FROM DATE ISSUED <br />JOB ADDRESS <br /> I/ to0 (A). germ 4-6 Ave., <br />CROSS STREET <br />OWNER NAME N14641Cif (An' Stet/ . LIVIA Ly uv‘. <br />OWNER ADDRESS 2e1 .2... I Notott... "XI VI CITY/STATE/WC OMNI- 1-1': P44lti Effer/PrIE <br />CONTRACTOR (Ii fyibieja C;i1V11031111,044-1 1rezik11,0[001 PHONE(707) (1-13f 41 ZR vli; <br />CITY/STATE/ZIP CONTRACTOR ADD <br />SUBCONTRACTOR ADDRESS 50 Howe- M. <br />S°PHif104:1'EllkrtO nil )jCiraia ile:°?5612 <br />ADDRESS 23) er P 1(-:4 ns SA-. <br />SUBCONTRACTOR GreetciDit lk ivy) <br />°Ty/sm./zip Wadi ra.-z-- , CA , <br />o <br /> , - 3 <br />LICENSE IIIC-57 Dc-61 DD-o9 0 Other NUMBER 1W St C2 S EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X le !..; (19t-.)551.14 rrtElY 4'1+(b2 tr, NI Township Range section <br />TYPE OF WORK je-New Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole <br />.5 Monitoring Well(s) 3 number of wells EX Soil Boring(s) 7 number of bonny <br />0 Well Destruction 0 Out-Of-Service Well <br />0 New Pump 0 Pump Replacement 0 Pump Repair <br />WELL CONSTRUCTION . <br />Drilling Method 0 Mud Rotary 0 Air Rotary S Ati !errii 0 Cable Tool 0 Push Point 0 Other .b I reci--7)u_St,.._ <br />Proposed Wen Depth 2 i'.. ft Excavation in diameter 0 Open Bottom Pi3 Oravel-Pack / Gran& gin t' 2_ in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth it u.,,,,,vicel Fct t Y., 1-:„.....4.4 <br />Well Casing Diameter ? in Thickness/Gauge/ASTM Sched 4C) 0 Steel 2Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth I - 1 t; ft -lc Neat Cement (94 lb bag / 5-10 gal water) 0 Sand Cement sack mix /7 gal water <br />Iiii,Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Grout Placement Method 0 Pumped XI Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By it Driller 0 Pump Contractor 0 Other <br />gl Concrete Pedestal Dimensions: Width -- ft Length 2- ft nick A in .RChristy Box 0 Stove Pipe <br />PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br />Well Diameter in Total Depth ft Depth to Water ft 0 Casing to be Perforated from ft to ft <br />Sealing Material 0 Neat Cement (94 lb bag / 5-10 gal water) 0 Sand Cement sack mix / 7 gal water 0 Bentonite Pellets <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Placement Method 0 Pumped 0 Free Fall 0 Other <br />0 Complete with Mushroom Cap ft 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 <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION A4 <br />%1111 ,SiC _Ai/AT <br />4111521166, HOUR ADVANCE NOTICE REQUIRp FOR INSPECTIONS <br />SIGNED <br /> <br /> TITLE :74 2/ -4;7/7 al 2 C /AT E / <br />Soik4+1 (impel krt APN <br />Man-teeit CA <br /> PARCEL SIZE 2 aCA e <br />PlIONE(q4C1 ) 751- 75)3 <br />0 Other <br />0 Geotechnical <br />0 Out-Of-Service Well Renewal <br />0 Cross-Connection Repair <br />number of borings <br />_A Li <br />28 <br />Area / Employee IDS <br />1:1 SPECIAL Well Permit <br />El WAIVER Received <br />Constructed Well Depth ft <br />PE SC <br />Info <br />Amount <br />Remitted <br />Checka/ <br /> Cash <br />Received <br />BY -I) <br />Permit/ <br />ice Request # Invoice # Well ID# <br />'%1 <br />Codes <br />In T 9 r,..---------------.___....._ <br />EHD 43-02-006 <br />2/14/2003 V173'/, Master Water Well Permit.doc