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WELL 1 PUMP PERMIT <br /> SAN JOAQum COUNTY F.NV rRONMF.NTnI.HEAT TF1 DEPARTMENT 304 E WEBER AVE 3M0 FL-STOCKTON CA 952112 - (209)468-3470 <br /> NON-REFUNDABLE PERMIT CALL(209)933-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> I � <br /> JOB ADDRESS W q 11�-1 "—'• L t 1 rV CITTIZIP X �J } <br /> CROSS STREET r /�y� APN �-S 13 G� �E� PARCEL SILL:vL 9 !' OLA\D USE APPLICATION 9 <br /> OWNERNAME II/y�ir7 1 1� n,lt� <br /> OWNERADDRESS((l 1 a!/1 E, o 1 oo CITYISTATLgAP i ► 1 X1-7�y�/ <br /> CONTRACTOR d9' 1 V' C H4J.NE q y <br /> CONTRACTOR ADD1tE3S - ( _CR <br /> SUBCONTRACTOR PHONE <br /> SURCONTRaM'OR ADDRESS CI[[TYIST�AITEIIZIP r <br /> LICENSE ❑C-57 (3C-51 Cl i}D4 CI Other NUMBER ILf O OC/1,1 r�XxPIRA'rloN DATE 0jk5--- <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ronne Section <br /> INTgNDED I:$F Dame5t5c,1PItVaIG ❑JrrigatioolAgoculmral LJ Industrial ❑water Qualiry Monitoring ❑Soil SamplingfCharacterization <br /> ❑Public Water$ysle,-t <br /> Ifdli.WtFrom ncr; aur vseem ame gia¢jFlame a;p+rm,� ° ` <br /> TYPE OF WORK ❑New Well ❑Repiacement Well ❑Well AlleraliunlMDdification ❑Test Hole ❑Other �. <br /> ❑Monitoring Well(s) #afwells ❑Soil Borings)_ Morlwdnp 0(3cowlinical a'oFporings <br /> L[Well Destruction ❑Out-OF Scrvicc Well ❑OurofServicr Wc11 Renewal <br /> X l.w Pump Pump Replacement ❑Pump R it ❑Cross-Connection Repair <br /> WELL CONSTRUC-TION <br /> Drilling Meshod ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Teal ❑Push Point ❑(),her <br /> Proposed Well Depth H Excavation in diameter ❑Open Bottom ❑Crave!Patk/Gravel Sin in diameter <br /> ❑Conductor Casing in diameter I Canductot Casing Depth ft <br /> Well Casing Diameter in Thicknes5ldaugefASTMSched. 13 Steel El plastic ❑Stainless steel ❑tither_ <br /> Grunt Seal Depth R a heat Cement(94 th 6.613-10 gal w.1er) ❑Sand Cement sack wk 17 gal water <br /> M++ <br /> 0 Bentonite(2(P/.solids) ❑Manufu�turrs Sprt%sulcds °k Name ❑Specs on File ❑Spms Submitted 13 <br /> Groot Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Retardant!Accelerator(name) C�( <br /> PEDESTAL Installed By ❑Driller O Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dlmenslans: Width ft T.engrh ft Thick in O Christy Box ❑Stove Pipe <br /> POMP Submersible ❑Turbine Cl Other HP,-.� Pump Set ft Standing Water Levet Q <br /> WtLL DESTRtcff0N ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other _ <br /> Well Diameter in Total Depth fi Depth to Watcr ft ❑Casing to be Perrurated from ft to _$ <br /> Scaling Malcrial ❑Nml 0=enl(9416 bx g/3-10 Xv(water) ❑Sand Cement sack mix 17 gal water ❑Bemmnite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%v solids___% Name __ ❑Specs on File ❑Specs Submitted <br /> Plnrement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Cnluplgp:to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WH SAN <br /> JOAQUIN COUNTY ORDINAICES, STATE LAWS, AND RULES AND RECULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUkKEN7-AND ACIIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIUM 24 HOUR ADVANCE NOTICE RE U1ltE R INSP1 CTIOIV� <br /> SIGN' TITLE - ATF. <br /> zt, Ir-N <br /> 4.1 8 <br /> G <br /> E r <br /> L A 7 <br /> DEPARTMENT USE O`NL C1 <br /> Application Accepled By_ _-- Date l tP Area l r3 -- Employee IDJf ` �, ` �1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> By <br /> Pump lnspcerior. nate ❑ WAIVERReceived <br /> Destruction TDSpection By Date Construcled Well Depth ft <br /> COMMENTS <br /> PE SC Received ecluW Announs Dat eInvoice# well H3# <br /> Codes Into BY ICA-15— Remitted ,—Act Request <br /> EHP43-02-006 MASTER WATER WE LL PERMIT <br /> 1212x2003 <br />