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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 XWater Quality Monitoring 0 Soil Sampling/Characterization <br />Contact Name or Phone Number Water System Name <br />Employee ID# <br />0 SPECIALVell Permit <br />WAIVER Received <br />Constructed Well Depth <br />4,3 <br />Area <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave 3"" FL - STocicron CA I2J1,LA tip <br />WELL / PUMP PERMIT <br /> OR <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />N. do -1)-(--r5iT1. Alan s lock 64 <br />[14i110/114 L-Velt APN teeil tout/al IA rola-of:kw' PARCEL SIZE <br />0 -Kki• Ful-3 Wad')PHONE 2m q3 g349' <br />tiA0VIIJAVA PrIqi fl <br />CONTRACTOR ADDRESS 55o RW-01. R1. <br />SUBCONTRACTOR COIASti 114Y11 5kYcill5 <br />3130 (Avetuovl Paid< Dn. Suik 6.50 <br />e 1 <br />CITY/STATE/ZIP 6Id1G1 PO4//c TY•08 <br /> <br />EXPIRATION DATE 0 Other NUMBER <br />GEOGRAPHICAL INFORMATION: Coordinates X <br /> Township Range Section <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />42. c.TysTAmmp Pahrut 64- Taz3 <br />PHONE 767-37y-4v <br />v kcA qii511 <br />puoN E 550 41 -,2067Z <br />CITY/STATE/ZIP <br />SUBCONTRACTOR ADDRESS <br />LICENSE WC-57 0 C-6I 0 D-09 <br />0.) <br />TYPE OF ORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification <br />0 Monitoring Well(s) <br /> number of wells <br /> <br />0 Soil Boring(s) <br />n Well Destruction 0 Out-Of-Service Well <br />0 Test Hole <br /> 0 Other <br />number of borings <br />0 Geotechnical number of borings <br />0 Out-Of-Service Well Renewal <br />Cross-Connection Repair :SS3110313V 3.1.1S WELL CONSTRUCTION <br />0 Mud Ro4rot3y 0 Air Rotary Auger 0 Cable Tool 0 Push Point 0 Other Drilling Method <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack / Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ti <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag / 5-10 gal water) 0 Sand Cement sack mix 17 gal water <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set II Standing Water Level fl <br />0 0 Bottom ti(Gravel Pack 0 Uncased 'it Other Wed e kith' Ou+ hal l (Ai oi flu &5 WELL DESTRUCTION en <br />Well Diame in Total Depth 73 ft Depth to Water 3% ft 0 Casing to be Perforated from ft fo ft <br />Sealing Material eat Cement (94 1/I hag/5-l0 gal water) 0 Sand Cement sack mix I 7 gal water 0 Bentonite Pellets <br />0 Be tonite (20% solids) 0 Manufacturer Spec % solids <br />-% <br />0 Specs on File 0 Specs Submitted <br />Placement Method r,l(Pumped 0 Free Fall 0 Other U-4- ----e)DP\E: <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 I A <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 LAWS, <br />SIGNED .4.1; m:17 TITLE Pajed- [44)5i S e&.7'477 DATE 7-11-03 <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />NO. <br />a>trva GIA) <br />21 /441-e" 44/c--of <br />to <br />f`. <br />1 WA) <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Application Accepted By <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By <br /> 40/. <br /> <br />Destruction Inspection By Date <br />COMMENTS <br />&eV/ • .•••- I I V u. . <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Bv <br />Check/// <br />Cash <br />Amount <br />Remitted <br />Date _....aargi oice # Well ID# <br />35o2. i a 1 -g-AMINVIIMIIME M.,,, co 55 ( 1 0 <br />. A CTrO warm g Writ PFRMIT <br />EHD 43-02-006 <br />b reemnb