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JOB ADDRESS <br />Cross Street <br />Owner Name <br />ClTV/STATE/ZlP <br />Contractor <br />City/State/ZipContract or address <br />Phone Subcontractor <br />Subcontractor Ai :ESS <br />Expiration Date Other D-09 C-61J-57License <br />Section Y X <br />Intended Use <br />Type Of Work number of borings <br /> Pump Replacement <br /> Cable Tool <br />[Erflastic <br />d-in <br />ft Turbine <br />ft <br />■AT] <br />CE <br />Title <br />I <br />4 CY <br />c <br />Area— Liatj; <br />Date <br /> Waiver ReceivedDate Pump Inspection By <br />ftConstructed Well Depth Date <br />Well ID#Invoice #Date <br />I <br />MASTER WATER WELL PERMIT <br /> <br />f <br />Amount <br />___ Remitted <br />IM f <br />El l D 43-02-006 <br />5/7/2002 <br />Well Casing <br />Grout Seal <br />~\Z:'Z. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> Other <br />______sack mix / 7 gal water <br /> Specs Submitted <br />Destruction Inspection By <br />COMMENTS __________ <br /> Employee ID# <br /> Special Well Permit <br />8 <br />PE <br />Codes <br />SC <br />Info <br /> Test Hole <br />number of borings <br /><Che|M<-^ <br />Cash <br />'■11c <br />Received <br />> g <br />I <br />GO U? <br />^2-- <br />Permit/ <br />______a*C(_______Service Request # <br />Sieoo 31302 <br />SQUIRED FORJBSPECTIONS <br />3.3 <br />Geographical information: <br /> Dmpestic/Private <br />E"njblic Water System <br />If different from Owner: <br /> Other___ <br /> Geotechnical <br /> Out-Of-Servicc Well Renewal <br /> Cross-Connection Repair <br />C^: . <br />4^ —- <br />de ^artmentuse^ <br />Application AccepteiUBv^y^ <br />Grout Inspection By \/j, kZ\ <br />D'Pumped Free Fall <br /> Driller <br />Dimensions: <br /> Uncased <br />Depth to Water <br />□ Neat Cement (94 lb bag/5-10gal water) O Sand Cement-------- <br />□ Manufacturer Spec % solids% Name <br /> Free Fall Other <br />ft below grade Complete to Existing Surface Pad <br />APPLICATION AND THAT THE WORK WILL BE DONEJN ACCORDANCE WITHi^SAN <br />- ---------j COUNTY ORDINANCES, STATE LAWS, AND RULES ANDJRJJGULATIONS. I--------------------- ------ <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRAC ' <br />WORKERS COMPENSATION LAWS. C <br />./■■)/) I M/N1MUM 24 HOUR ADVAW <br />Signed <br />Coordinates <br /> Irrigation/Agricultural Industrial <br />Water System Name <br />MW <br />■ <br />Parcel Size * 1 tA U <br />Phone <br />Tar/o eY <br /> Township Range <br /> Water Quality Monitoring Soil Sampling/Characterization <br />____ IZM GfW/M k___________ <br />’Contact Name or Phone Number <br />Fl - Stockton CA 95202 - (209) 468-3420 <br />,RES 1 Year from Date Issued <br />■Txt ■ <br />____ City/State/Zip <br /> Push Point Other <br />B'Cravel Pack / Gravel Size^X/^ in diameter <br /> Stainless Steel <br />B>5and Cement/ / <br />Name Specs on File <br /> Retardant / Accelerator (name) <br /> Christy Box Stove Pipe <br />ft Standing Water Level <br />D'Mud Rotary Air Rotary Auger <br />Depth ^OO ft Excavation_ 12)in diameter Open Bottom <br /> Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/Gauge/ASTM Sched <br />Depth One/ n <br /> Bentonite (20% solids) <br />Grout Placement Method <br />Installed By <br />BK^oncrete Pedestal <br /> Steel <br /> Neat Cement (94 !b bag / 5-10 gal water) <br /> Manufacturer Spec % solids% <br /> Other_________________ <br />E^ump Contractor , Other <br />Width It Length -^7 Thick <br />□ Other. HP I <br />Pedestal <br />Pump Submersible <br /> New Well UZlGplacement Well Well Alteration/Modification <br />□ Monitoring Well(s) numbe of q goH jjoring(s) <br /> Well Destruction Out-Of-Service Well <br /> New Pump Pump Replacement Pump Repair <br />Well Construction <br />Drilling Method <br />Proposed Well <br />VV JLiXjAj t i tJIVAi A AJAXJ.VAA A <br />/)uin County Environmental Health Department 304 E Weber Av <br />4-Refundable Permit (209) 953-7697 for Inspections L <br />IULQO ClTY/ZlP <br />ffiTVC/g IFCM _______ APN 0^-02/) - t^Z <br />Well Destruction Open Bottom Gravel Pack <br />Well Diameter in Total Depth ft <br />Sealing Material <br /> Bentonite (20% solids) <br />Placement Method Pumped <br />j Complete with Mushroom Cap <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS <br />JOAQUIN <----------- -------------------- _’2 <br />v <br />Pump Set <br /> Other <br />ft Casing to be Perforated from ft to I <br />sack mix / 7 gal water Bentonite Pellets <br /> Specs on File Specs Submitted <br />Owner Address <br />^00 S.