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WELL 'IMP PERMIT <br /> ,`SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT swe 304E WEBER Avu 3""FL-STOCKTON CA 95202,,.0i))468-3420 <br /> NON-REFUNDABLE PERMIT r CALI, 209 953-7697 FOR INSPECTIONS fEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOu ADDRESS 6 /]� C Y— C T%IZIPr <br /> tR <br /> a • <br /> CROSS STREET L / APN PARCEL SIZE <br /> OWNER NAME All; cfs PHONE <br /> OWNER ADDRESS >✓r RL L'-A�� ,. CITYISTA'TI1JZIP 40-&±4LO <br /> CONTRACTOR (yy,!?}� (/LCI—yV�y�y'C _.. --_ �P'IIOONNF/��4' ' <br /> CONTRACTOR ADDRESS_y�U'r 1 f 1 f//�/ cis S�- CITY/STATVZIP <br /> SUBCONTRACTOR—AfTf— PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE)ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑p-09 ❑Other NUMBER ExrltrnnoN part. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangeIFSertiOn� <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural 11 Industrial 0 Water Quality Monitoring wXSoil SamplinglChamGerization <br /> ❑Public Water System <br /> It dfRerenr From0-: mer.ys.am anw Contacl an—Phnnc Nunn,r <br /> TvPE OF WORK ❑New Well ❑Replacement Well Q Well Alteration/Modification ❑Test Hole ❑Other <br /> M MonitoringWells number of wells �(SUil 80rin s umber oT6orinys numb—lb <br /> O , g(1 a ©Gcoteehnical <br /> 0 Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Rump Repair ❑ClOSS-COnnection Repair l <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary r ❑Air Rotary ❑Auger 13 Cable Tool L3 Push Point �lher <br /> Proposed Well Depth e_,--it Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Sea] Depth R ❑Neat Cement{941h hag/5-10 gal vuier) ❑Sand Cement suck mix 17 gal water <br /> ❑Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name ❑Spews on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fal] ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ fl Lcngth iI Thick in 17 Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level fl i <br /> WELL.DESTRUCTION ❑Open Bottom 0 Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth R Depth to Water Fl ❑Casing 10 be Perlbrated from A to it I <br /> Sealing Material Xeat Cement(941h bag/3-10 gal muer) ❑Sand Cement rack mix 17 gal water ❑Bentonite Pellets T 3 <br /> ❑Bentonite(201%solids) ❑Manufacturer Spcc%solids % Name ❑Specs oil File ❑Specs Submitted + <br /> Placement Method 0 Pumped 4ree Fall ❑Other <br /> 13 Complete with Mushroom Cap fl belnw grade ❑Complete to Existing Surface Pad <br /> 1 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> 3 <br /> If 1. <br /> • OA iJif IX UN FY <br /> v <br /> DEPARTMENT USE Y yy <br /> Apphea:i0n Accepted By`-51-4y _ Date U - Area Employee IDN <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received - <br /> Destruction Inspection By Dale Coustrucied Well Depth fl <br /> COMMENTS <br /> PE SC Amount Checkgl Received Date Permit/ lnvoiceN WeIIIDif <br /> Codes nfo Remitted Cash By, Service Re u s f! <br /> SE <br /> 3 <br /> EHD 43-02-006 <br /> 5n12002MASTER WATER WELL PERMIT <br /> VVV LLL <br />