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INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial <br />0 Public Water System <br />If different from Owner. <br />0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Contact Herne or Phone Number Water System Name <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE Fitn/. Sa/'71-RV/saie DATE I SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Destruction Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />ate <br />Date <br />Li. Area Emp oyec ID# <br />iteS4 0 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth <br />Mi <br />ft <br />HEICE_NrIED WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave 3.° FL - SroceToN CA 95202 - (209)460-3420 <br />Mk-REFUNDABLE PERMIT CALL (419) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />.30350 S r,exe Rz <br /> APN <br />R/Y l'iffe//C/C ),22/.44 5 <br />CITY/SEATE/Zir <br />PHONE <br />CONTRACTOR ADDRESS <br />CI TY/STATE/ZIP <br />LICENSE U (2-61 0 D-09 0 Other NtlatttElt _57 76'519 EXPIRA1 ION DA1E a <br />CV.00RA PHICA INFORMNI ION: Coordinates X Y Township Range Section <br />TYPE Or WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification <br />1:PCMonitoring Well(s) .2 number of wells p Soil Boring(s) <br />0 Well Destruction 0 Out-Of-Service Well <br />0 New Pump Pump Replacement 0 Pumtt Repair <br />0 Test Hole Other, <br />nu"th" b'i"g' 0 Geotechnical numb(r of bOriegs <br />0 Out-Of-Service Well Renewal <br />' <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary CI Auger 0 Cable Tool 0 Push Point X. otherfihe M9emekA,P_/1.4e4.) <br />Proposed Well Depth / '5/0 ft Excavation y in diameter )4Open Bottom 0 Gravel Pack / Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter 'Y in Thickness/Gauge/ASTM Schcd '90 0 Steel "Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth "Nl.e 0 ft 0 Neat Cement (94 lb bag / 5-10 gal rooter) 0 Sand Cement sack mix /7 gal water <br />Benton ite% solids) 0 Manufacturer Spec % solids dr % Name CI Specs on File 0 Specs Submitted <br />Grout Placement lif ethod )(Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed BY linDriller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box Pipe 1 4Stove <br />PUMP Submersible 0 Turbine 0 Other HP Pump Se(V30 B Standing Water Level 'N/25 ft <br />WELL DES11IUC14ON 0 Open Bottom 0 Gravel Pack 0 Uncascd 0 Other <br />Well Diameter in Total Depth It Depth to Water ft 0 Casing to be Perforated from II to ft <br />Sealing Material 0 Neat Cement (94 lb bag / 5-10 gal water) 0 Sand Cement sack mix 1 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 WITII THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERVOM ENSAT1ON LAWS. <br />PE <br />Codes <br />SC <br />Info <br />Amount <br />Remitted <br />Check/4/ <br />Cash <br />Received <br />B .,,,.., _ .____ ate Permit/ <br />Service Request 9 Invoice # Well ID# <br />5C) 31100 bi ' lir'', 2164 3g - 79$ <br />I <br />END 43-02-006 <br />8/20/2003 61.3"'"tegr <br /> <br />MAY 19 <br />/IRONMEN1 <br />PERMIT/SE <br />JOB ADDRESS <br />iiLAUFUT <br />OWNER ADDRESS <br />CONTRACTOR <br />SUBCONTRACTOR <br /> et)/4 <br />SUBCONTRACTOR ADDRESS <br />Box <br />c254 r 41s r <br />'73/Rerse-A)24 <br />2>R1-4-Z/A/G <br />4//eAltre CITY/STATE/ZIP <br />re/Zir rie4C c' a 3 A6 <br />PARCEL SIZE <br />PHONE 05)1X 87E97 <br />Retzw.iro,v, 5S-us(4 <br />‘20,1_20.2‘29 <br />co-0-44,A,c.c7. p33,5 <br />PIIONE