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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 314E WEBER AVE 3Y°FL-STOCK <br /> 'rON CA 95202-(209)468-3920 <br /> NON-REFUN ABLEPEERRMIIT r CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> �/ oH/ y� <br /> • CROSS STREET - W O41 APnO7�CrInTIZJreV (`TPOA�RCEL SIZE j C�0O66 <br /> OWNERNAME AA�1,4010,OKGS k ZjA e,4 PHONE 11/07- <br /> OWNER <br /> np <br /> l <br /> ADDRESS _ CITY/STATTZIP <br /> CONTRACTOR I- m l( PHONE <br /> CQNTRACTORADDRFSS 1-4 CITY/STATE/ZAP &"a <br /> 6^ <br /> SUBCONTRACTOR <br /> — PIIONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C C-61 ❑D-09 ❑aner NUMBER � /^� EXPI RATtOry DATE b MO <br /> GEOGRAPHICAL INFORMATION: CDardimiles X V T.—hip— Raoge_ Settle. <br /> L3Domestic/privale 13Irrigatioa/Agrieultural O Indusrial ❑Water Quality Monitoring ❑Soil Sampling/Charaelerization (�11 <br /> O Public Water Sm- <br /> INTENDED USE O <br /> Irdift..fmm Amor. uer yslem are C-1Nme ur ;i64 <br /> TYPE OF WORK ❑New Well ❑Replaecment Well O Well AlteratiotdModificarion O Test Hole ❑Other <br /> 13 Monitoring s numaermf wells mrnSrr ofbariny-f numbv orhodnp <br /> B Well ❑Soil Borings)— ❑Cxwtechnitzl <br /> O Well Deswction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement O Pump Repair ❑Cross-ConrKcoon Repair <br /> WELL CONSTRUCTION <br /> DHHI.g Method ❑Mud Rotary ❑Air Rotary ❑Auger O Cable Tool O Push Poim. O Other <br /> Prapi—d Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing mdiemeter / Conductor Casing Depth _tt <br /> Weil Casing Diameter_in Thickru:WGauge/ASTM Sched ❑Stcel ❑Plastic ❑Stainless Steel ❑Other 3 <br /> Grout Seat Depth ft ❑Neat Cemm((94 lb bol'/5-10 gal walcr) ❑Send Cement .rack mfr/7 gal water <br /> 17 Bentonite(20%solids) ❑Manufacturer Spec%solids_% N.--- ❑Specs on File O Specs Submitted <br /> Grout Placement Method O Pumped ❑Ftce Fall ❑Other O Rcuurdant/Accelerator(mere) <br /> PEDESTAL Installed BY ❑Driller O Pump Contractor ❑Other <br /> O Concrete Pedestal Dimensions: Width__It Length_R Thick in O Christy Bos ❑Stove Pipe <br /> PUMP ❑Submersible O Turbine ❑Other HP Pump Set Il Standing Water Level ft <br /> WBLI.DESTRUCTION ❑ Bottom O Gravel Pack O Uncased ❑Other <br /> ter�i <br /> Well Diamen Total Depth�cI R D.pth to Wstcc rj�R O Casing to be Perforated/from_ft to ft <br /> Sealing Material ❑Neat Cement(94 th hag/5-10ga1—n,,) ❑Sand Cement sack mit/7 gsl watu 1anbnite Pellets <br /> • ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name O Specs on Fiie O Specs Submiµed <br /> Placemaa Meth od ❑Pumped O Free Fail ❑Other_ <br /> Complele with Mushroom Cap R below 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. 1 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 COMPENSATION LAWS <br /> /J7 MII/�'IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Y� yv <br /> SIGNED l�G..i•(( /7jt.(]V TITLE O�M;/t� DATE S_ 'I L/3-0- <br /> r <br /> to <br /> 7 i. <br /> I <br /> DEPARTMENTEONLY` �r�y� <br /> Application Accepted By Dale '?.3 Q A. _ Employee)DII Jilt- <br /> - <br /> l - <br /> Grow Inspection By Date ❑ SPECIAL Well Perrssit <br /> -' - Pump Impeclion By Dare <br /> ❑ WAIVER Received <br /> Destruction Inspec:(ion By Date �i o <br /> - Caeserueted Well Depth_ D <br /> COMMENTS <br /> r <br /> SC AmountCheckJN Received <br /> Codes Info Remitted By Due -i-Re uestA lovoice l{ Well lUe <br /> "1� i6 fS Sena <br /> EHD 43-02-006 <br /> 5,7/2002MASTER WATER WELL PERMIT <br /> i <br />