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r WELL/ TMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONAIFNTAL HEALTH DEPARTMENT 141011,", 304E WEBER AVE 3"FL-STOCKTON CA 95202 468-3420 <br /> NON-REFUNDABLE PERMIT CALI, 209 953-7()97 FOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS -V i-`-E C YIZ.IP M <br /> /� // r A o <br /> CROSS STREET 1>4- APN J�rs f� Y{. !�v pARCELSIZF. V <br /> OWNER NAME <br /> ,1 PHONE <br /> OIYNEA ADDRESS W ' CITYfSTATFJ"ZIP��//y-l'S�•�[.�/eTii <br /> CONTRACTOR _f �_� "LCC(�J�. 1YLc PHO`NF`7�7 — <br /> CONTRACTOR ADDRESS IL-Z GG" CITYISTATFJZiP <br /> SUBCONTRACTOR ... PHONE <br /> I <br /> SUBCONTRACTOR ADDRESS <br /> CITI'ISTATEIZIP <br /> I _ <br /> LICENSE 0 C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township��Range�.--.Section _<7-5'— <br /> INT£NDeD Use 13 Domestic/Private ❑IrngationfAgricullural D Industnal ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System ! <br /> lfdiff—i from Owntn Witur Systorn arae °nine[ arae°r unr um er <br /> TYP£OF WORK ❑New Well 0 Replacement Well ❑Well Alteration/Modification ❑Test Hole \Other <br /> ❑Monitoring Well(s) °°'"tiff of well' `OrSoil Boring(s) _ nuri6"0r6orkngs 0Geoiechnical V1"�Cf°rh°`I"� <br /> ❑Well Desm ction ❑Out--OGServiec Well ❑Out-0F-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair Q Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rosary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 0 Usher <br /> Proposed Well Depth__ r it Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth Il <br /> Well Casing Diameter_in ThicknesslGaugc/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth It ❑Neat Cement(94 1b bag 15-10 ged warm) L7 Sand Cement .errcA mix 17 gal water <br /> ❑Bentonite(21)0/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on file ❑Specs Submitted <br /> Grout Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed 0 ❑Driller O Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions' Width it Length B Thick in O Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine 0 Other HP Pump Sct tl Standing Water Level It r <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other I <br /> Well Diameter in Total Depth tl Dcpth to Water tl O Casing Io be Pertbraled from R to A ' <br /> Sealing Material )'Float Cement(94 th bag 15-10gaf wirer) ❑Sand Cement .rack mfr 17 gal water ❑Bentonite Pellets T— <br /> ❑Bentonite(20%soiids) 0 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted s <br /> Placement Method O Pumped tee Fall ❑Other <br /> ❑Complete with Mushroom Cap B below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M[N1MUM 24 ADVANCE NOTICE REQUIRED FQR INSPECTIONS <br /> SIGNED TITLE DATE <br /> y <br /> Ir I <br /> 1 <br /> tiNJ A <br /> HE 1711 i's' <br /> f DEPARTMENT USE ON <br /> Application Accepted By�1( t e Date ONLY 3 Area rmployee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth_rt <br /> COMMENTS <br /> PE SC Amount Check#! Receive Date Pcrmitl Invoice# WeI11A# <br /> Codes Info Remitted Cash Service Request# <br /> Oq a 3 � <br /> 3 <br /> EHD43-02-006 rD MASTER WAl'ER WELL PERMIT <br /> 5!72002 <br />