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IY L' LL / 1'U1v1Y Y_ Lt ItivII l SAN JOAQUIN COUNTY ENVIRONMENTAL HEACI' .uEPARTMENT _Q304 F.WEBEHti YE I"'FL-S"1'OCKTON CA 95302 - (209)468-7420 NON-REFUNDABLE PERMIT "ALL 209 953-7697 FOR INSPECTIONS PIRES I YEAR FROM DATE ISSUED JOB ADDRESS a F(•O C •� CITY/ZIP - I CROSSSTREET Q APry / 7n � o PARCELSIZE � � � p OWNER NAME ( p�,, y� _ �,� � •lL\ PHONE OWNER ADDRESS 1.( Sr 1 r v�-- if CITY/SfATFJZB, CONTRACTOR - PRONE CONTRACTOR ADDRESS Gll'Y/STATEIZIP -t�I SUBCONTRACTOR PHONE J SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INF MATION: Coordinates X Y Township _ Range Section INTENDED USE Domestic/Private ❑frrigalion/Agricullumi ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterimlion ❑Public Water System irdifferem from Owner: W.ter Sysmm ame Contac[Nanmorrh..e u r TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Bole Other ❑Monitoring Well(s) numberofwdls ❑Soil Boring(s) nu 1,e,.r1xnngs ❑Geolechnical ^m tber of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal O New Pump 0 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair ' 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 it Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth tl ❑Neat Cement(941b hug/5-10 gal wafer) ❑Sand Cement .tuck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped O Free Fall ❑Other O Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ ft Length fl Thick in ❑Christy Box ❑Stove.Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ti Standing Water Level It WELL DESTRUCTION O Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth Il Depth to Water Il ❑Casing m be Perforated from It to ft Sealing Material ❑Neat Cement(94 lb bug/5-10gal wafer) 11Sand Cement .suck oris/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 R below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMU �24 HOUR ADVANCE NOTICE REQI)IRED FOR INSPECTIONS SIGNED ' TITLE lCrrA�>1J�� DATE e L � 1 IJ r 1 lit ct S Iph p11 1 DEPARTMENT US ONLLY U()` Application Accepted By f z- Date ?� (/ Area Employee ID# 0 Grout Inspection By ///yy1� ��//}--- - ' - Dale ❑ SPECIAL Well Permit Pump Inspection By /.(.✓er4,yv /P�` Date 9�7 ❑ WAIVER Received Destruction Inspection By(/71�'�� Date Constructed Well Depth ft COMMENTS �i �- PE SC Amount Check#I Received Permit! Codes Info Remitted Cash - By Datc Servicc Re uest# Invoice# WeII1D# ' U - 2 fl3 �S EHD 43-02-006 MASTER WAl'ER WELL PERMI"r 5/7/2002