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/(/t WELL 1 PUMP PERMIT 413,. SAN !o UIN COUNTY ENVIRONMENTAL HEALTH RTMENT 304 E WEBE E 3"'"Fl.� T - (209)468-3420 NON-REFUNDABLE PERMIT i,-_ .CALL 209 953-7597 FOR INSPECTIONS 1XPIR A-DATE ISSUED JOB ADDRESS Ln CITY/ZIP M ��+e-� a CROSS STREET 11 V 0- M i t APN -�C.J PARCEL SIZE OWNER NAME 4 'a 0 P OWNERADDRESS0. 5�� CT CITY/$TATEIZIA 1 �figg CONTRACTOR 5 I� PHONEOM CONTRACTOR ADDRESS . D• &A_ CITYISTATFJZIP��CQ�C_�5 :3-7' SUBCONTRACTOR M�\\S• PIiON•E 111(�` •31G O—56LI I x SUBCONTRACTOR ADDRESS��->` ( i C[T�Y/SSTATEIZIP_SO ! \ � �� LICENSE C-57 ❑C-61 ❑D 09 ❑Other NUMBER qIJIJ2 LOO EXPIRATION DATE 15101 09 GEOGRAPHICAL INFORMATION: Coordinates- X_ 0 55fQ�37q Y Vara 1,34 rWr Township Range Section INTENDED USE ❑PublicDomestic/PrivateteSystem ❑]rrigation/Agricultural Q Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water System 3 If different from Owner: ater ystem ame Contact Namu or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other (1, number of wells number oorin• y . 13 Monitoring Well(s) 11 Soil Boring(s) bf borings number of borinss 13Well Destruction. ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Cross-Connection R air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth tt Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ti I Well Casing Diameter n Thickness/Gauge/ASTM Sched ❑Steel C7 Plastic ❑Stainless Steel ❑Other Grout Sea! h ft C3 Neat Cement(941b hag l5-1 D gal water) ❑Sand Cement suck prix 17 gal wa[er PBelt"ite(201/o solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped ❑Free Fall ❑Other A6 ❑Retardant/Accelerator(name) ! l PEDESTAp,, n InstalledSv 13Driller ❑Pump Contractor 11Other ❑Concrete Pedestal Dimensions: Width tt Length ft Thick in ❑Christy Box ❑Stove Pipe j PUMP Submersible ❑Turbine . ❑Other HP Pump Set It Standing Water Level WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other ell Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealin A erial ❑Neat Cement(941h hagl5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method - ❑Pumped ❑Free Fall Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY.ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE.CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORK OMPENSA"f[ON LAWS. MINIMUM 24 HOUR ADVANCE NOTICE QUIRED FOR INSPECTIONS SIGN TITLE DATE NJI I R fVVY I O DEPART.MEIY_T U5 O Y r •. x.. r Application Accepted By Dare Area !mp'foyee!D J �. t Inspection Dale ❑ SPECIAL Well Permit Pump inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS !U (] / 'f' lZj i f �<* PE SC AmountCheck# Received Date Permit/ Invoice# WeII1D# Codes Info Remitted Cash ByService Re uest# Z 0- EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002