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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENEL�r A vasa iuaur314E WEBER AVE3Y4 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CAL^L�209 953-77697 FOR INSPECTIONS EXPIRES 1`1YEAR FROM DATE ISSUED <br /> JOB ADDRESS `l_CZ.,\ Q S—\—\\Ns�\ CITY/ZIP <br /> CROSSSEREUr A\ APN 1-13 - 300— VTI PARCELSIZE <br /> \' �Y Q �C �] C <br /> OWNER NAME L�P� _�CC� , \ PRONE �f��GVV]�a��(���a <br /> OWNERADDRESS \ ` �V CITV/STATEIZIP ` QA <br /> PRONE <br /> � <br /> CONTRACTORADDRESS \\-Sls \U` �C�Pi�I�RU 1�1 vL2r CITY/STATFIZIP��tX..4._"yV�'�`9A��"\r7 f�DS <br /> SUBCONTRACTORV \JP�c PHONE <br /> SUBCONfRACEORAODRESS \\� CITU/STATE/ZIP `v <br /> ` LICENSE C-57 C-61 0D-09 DOther NUMBER \ E%PIRATIONDATE Q <br /> GinficwRICALINFORMATION: Coordinates K V Township Range_ Section <br /> INTENDED USE rlleRUC/Privar4 ❑Irrigation/Agneultural ❑Industrial ❑Water Quality Monitoring O Soil Sampling/Chimoterienion <br /> L ❑Public Water System a time omen ,mew am <br /> lxr <br /> If otic W ter roc a ynrm <br /> TYPEOF WORK ❑New Well ❑Replacem,nt Well ❑Well Alteration/Modification ❑Test Hole 13 other �^ <br /> ❑Monitoring Well($) oomlarof—lk pSoil Bering(s) euft­ftrmns' ❑Geotechnical numbor Ott°m 1 <br /> A❑Well Destruiamn ❑Out-0f-Service Well ❑Out-Of-Service Well Renewal <br /> ` ew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Re it o <br /> WELLCONRIRUCTION <br /> Drilling Method ❑Mud Rotary O Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavatum in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> hra Well Casing Diameter_in TuekneSdGaagr/ASTM Schad ❑Steel Cl Plum, ❑Swint.Steel ❑Other <br /> Grout Seal Depth B O Nem Cement(94 It,Aug/5-10 gal wmrrJ ❑Send Cement fuck mix 17 gal water <br /> ❑Bentrni¢(20%solids) ❑Manufacturer Spec%Solids_% Nance ❑Season File ❑Specs Submined <br /> Grout Placement Method 0 Pumped O Free Fall ❑Other ❑Retardant/Aecelermr(name) <br /> hass PEOEsrAL Installed By O Driller ❑Pump Contractor ❑Other <br /> ❑Cousin.Pedesnl Dlmmrlo..: Wafth Il Length 0 Thick in 13 Chaffy Box ❑Stave Pipe <br /> PUMP _ Submersible ❑Turbine ❑Otho HP It <br /> Pump Sri I�XXR tan <br /> Sding Water Level <br /> WELL DESTRUCTION ❑Open Bmbm ❑GRVeI Peek ❑Uncured ❑Other <br /> see, Well Diameter in Total Depth R Depth w Water R ❑Casing to be Performed from R in R <br /> Sealing Material ❑Nat Cement(94/A haw/5.10 gal water) ❑Sand Cement ark sah/2 gal water ❑Sanatoria,Patient <br /> ❑Berefurte(20Y.solids) ❑Manufnetura Spec%solids_% Name ❑Spms on File ❑Spas Submiped' <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with M.A.Cap R below grade ❑Complete or,Esising Sorfae Pad <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Il DONE IN ACCORDANCE WITH SAN <br /> CURRUEJOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULER AND REGULATIONS. 1 ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> UM 24 HOUR ADVANCE N REQUI FOR INSPECTIONS <br /> SIGNED TITLE SAFE <br /> aR <br /> C <br /> f N <br /> LUE Nl <br /> R1 1'n -]M�wI DEPARTMENT USE ONLY <br /> L Application Accepted By VyAAF1T\LUJR,4, Date J — A 3 Area Employee IDUhg44 <br /> Grout Iapec <br /> sfion By may_ Dam [ISPECIAL Well Permit <br /> Pump Inspection Data .O �d ❑ WAIVER Received <br /> Dentmetion Inspersion By Date Constructed Well Depth R <br /> COMMENTS <br /> LPE SC Amount heekq/ Raefved Date Permit/ Invoice# Well IDU <br /> Codes ]nrn Remitted By Service Ra,.,,t# <br /> 43P� C)SG 5 Sb da 9 <br /> YK 00332-77 <br /> 6 <br /> E110,43-02-006 MASTER WATER WELLPERMIT <br /> 5/12002 <br />