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1--- W LLL I YUivlr rr,xuriui <br /> SAN J Q 1N COUNTY ENVIRONMENTAL HEALTH�''" ARTItitENT 304 E WEBEP-4WE 3""FL-STOCKTON CA 95202 - (2U9}468-3420 <br /> NON-REFUNDABLE PERMIT _- CALL 209 953-7697 FOR INSPECTIONS � XPIRES 1 YEAR FROM DATE ISSUED <br /> // / } CITYIZIP ,F�T'r/ <br /> 3 0� �A/ C <br /> JOB ADDRESS <br /> A P N�'7c 3 ,((L.� — PARCEL SIZE g <br /> CROSS STREET � <br /> PRONEOWNER NAME <br /> CITY/STATE/ZIP <br /> OWNER ADDRESS <br />' l PHONE <br /> CONTRACTOR r�r <br /> CITY/STATEIZIP /`�} <br /> CONTRACTOR ADDRESS �l V � ��fPl A4Z5 -— <br /> PHONE <br /> I SUBCONTRACTOR <br /> 1 CITYISTATEIZIP <br /> SUMONTRACTOR ADDRESS <br /> LICENSE I-6-57 ❑C-61 ❑D-09 ❑Other <br /> NUMBER EXPIRATION DATE C <br /> Y Township Range Section 3- <br /> ' GEOGRAPH1CALlNFORMATION:� Coordinates X <br /> INTENDED USE omestic/Private 0 Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring * ❑Soil Sampling/Characterization 5 <br /> ❑Public Water System mer ystem ama on[act ante or'one um er <br /> If different from caner: <br /> TvPE OF WORK ❑New Well eplacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of borings �n <br /> 'I number of wells numberofborings ❑Geotechnical <br /> II ❑Monitoring Wells} number Boring(s) <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Ot=Service Well Renewal <br /> ❑New PUMP Pum Re lacement ❑Pum Re air CJ Cross-Connection Repair <br /> WELL CONSTRUCTlO <br /> Drilling Method "ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other C, <br /> Proposed Well Depth /40 ti Excavation /O in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter �- <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ti <br /> Well Casing Diameter —W/—in Thickness/Gauge/ASTM Sched 140 ❑Steel astic ❑Stainless Steel 11 other C^ <br /> { Grout Seal Depth ft 13Ncat Cement(941h hug/5-10 gal water) ❑Sand Cement sack irrixl7 gal water <br /> ®'Bentonite�/(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ep mped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractortlter <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Q Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> ! WELL DESTRUCTION R16pen Bottom ❑Gravel Pack ❑Uncased Cl Other <br /> Well Diameter—6—in Total Depth wM _— ft Depth to Water It ❑Casing to be Perforated from tt to ft <br /> Sealing Material0 Neat Cement(941h hug/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ntomte %solids) ❑Manufacturer Spec%solids % Name ❑Specs on Fite ❑Specs Submitted <br /> a Placement Method umped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft 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 RECULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI N LAWS. <br /> MINI M 24 HOUR•ADVANCE NOTICE- QUI DF CTIONS <br /> SIGNED TITLE DATE D <br /> s "�4 <br /> �ti -j <br /> Y� <br /> AI <br /> �" •`g '•J €�w _ <br /> NI <br /> AO3 , 1� 1 <br /> N <br /> DEPARTMENT USE ONLY <br /> Appl'scation Accepted By �j 9�"�V Date -�I�.- Area ��q <br /> J Employee ID# <br /> Grout Inspection Date «��^<' 'r ;? _ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspectio. Date Constructed Well Depth /e) ft <br /> COMMENTS �`S' <br /> PE SC Amount Chec Received Date Permit/ Invoice# Well IDN <br /> Codes! <br /> Info Remitted ash r�BV r Service Request# <br /> OGO <br /> EHD43-02-006 MAS jP,J}tWCLLPERMIT <br /> 5/7/2002 PUB JOA 7 so,ACES <br /> ENV4RONMENIAL HEAVE i DIVlg10N <br />