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` WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 364 E WEISER AL 3Y1 FL-ST CKTON CA 95202 -(209)468-34IO NON-REFUNDABLE PERMIT CALL(709)953-7697 POR INSPECTIONS EXPIRES II YEAR FROM DATE ISSUED Jos 11ODRIE53 ��z1 ( e:�I{/,/ lPin I t,•I 7-f[! ^ CII Y>�.IP96 CRO.C4 STREET .Jc(l tfd ,�/ll.�ir PN —�. t/'� _PA kCEL SILL';)—C'7 AND USE APPLICATION#_ l � rye• e t � -- OwNERNAk1E t_C/JAI �[1I�-�11 .- _ PHONEYIZ, OWNERADDRESS t•r0"M-) +`7141 - C.rrvISTA'1'El4Fr� CONTRgCI'ORf/ ¢` PHONE ` r CONTRACTOR ADDRESS -(�ErJ` [} f�,f •n SUnCOmrRACTOR _ _ PHONE SUBCON'I-RAI:IDR ADDRESS CITWSTA'TEtZ3P LICENSE C-57 Ile:i 1 ❑D-09 11"her, NU'MRER F �7'lf EXYIRATION DATE GEOGRAPHICAL INFORMATION: 'Aurdinates X Y Township Range Section INTENDED USE ❑DomestefPrivate ❑[rrigatinn/Agncrdtnma ❑Industrial ❑Water Quality Monitoring 0 Soil 9dmpling/Chatacteri-r_arlon ❑Public Water System If d�Fkrcm fmm mer: Sler-ys.. ame -- - nU� aCr hsme ar wide,um e� TYPE OF WORx New Well ❑Repiacemenl Well ❑Well Alreration,'Modifieation O Test Ilote 0 Other ❑Monitoring Wells #ofwe➢s ❑Sail Qorin s °r6on"� Geateclhoicala al'hi+rings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ' ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cmss-Canneaiun Rcpair WELL CONSTRUCHON DrillinR MethodkMud Rotary ❑Air lto[ary 1-1Auger ❑Cable Tool ❑Push Point LJOther Proposed Well Depth ft Fxcavalirrnarr in diameter 0 Open Bottum 'Liravcl Pack!Gravel Sire in d7ame[er ❑Cond r Casing in dia--w f Conductor Casing Depth , ft Well Casing Diameter(Vin Thickrlessi0augelASTkf Schad O 7 ❑Sted O PWitc 13Stainless Steel C1 Other Grout Seal Depth fV ] R ❑Neat Cement(99 th bag 15-10 gut wntrr) ❑Sand Cement .ruck mix 17 gal water �@eatonilc(209A solids) ❑Manur=urer Spec%solids__% Name_ _ ❑Specs on File 0 Specs Submitted ,grout Placement Method Pumped OF—F.11 ❑Other_ ❑Retardant l Accelerator Inarrle) PEDT.STA4 Installed By ❑Driller RPumpCopira.ior ❑Other_ ❑Concrete Pedestal DlmeHsions: Width it Length 4 Thick in ❑Christy Roz ❑Stove Pipe PLRIF ❑Submersible ❑Turbine ❑Other_ HP _ Purup Se[ ft Standing water Level h -kj WELL DESTRUCTION ❑Open 9uttom ❑Gravel Pack C]Uncased ❑Other £� Well Diameter __in Total Depth it Deptt,to Watt:r _ ft ❑Casing to be Pertorated from it to ft Sealing Material ❑Neat Ctanent(94 lh hag 15-)0 gal water) ❑Sand Cement .rack mix 17 gal water ❑Bentonite Pellets ❑Scntonite(20%solids) t]Manufacturer Spec%solidr, % Namc _ ❑Specs an File ❑Specs Submitted Placement Method Cl Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Crap 11 below grade ❑Complete to Existing Surface Pad 1 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 RECULATiONS. I ALSO CERTIFY THAT MY RF,QUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. /+ ` MINIM INIMU 24 HOUR ADVANCE NOTICE REQ /IRE D FOR INSPECTIONS n SIG �"NED j[� OVA TITLE.TITLE. i'Ib 1i vI _ DATE r it I '-j 1 L mt .10 L14 1 ip J A DI C r . ns Irt LA T _ DEPANT ENT U E ON Y p Application Accepted BY Date 'I- }�- r - Arca �� d Employee[D# �fJ Grout Inspection ey Date -� ❑ SPECIAL Well Penult [ PumpinspceiianBy Date_- ❑ WAIVERReeeiveil Destruction Inspection By Date Constructed Well Depth D commrNTs 61d Coo- PE SC Received Amount to PvrnafL Invoice# Well ID# Codeslate B Cash Remitted •rvicc e t# 3.cb 1 c � tial Al IIID 43-02 OM MASTER WATER WELLPERMIT 12:27'200]