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7,D <br /> WELL/PUMP PERMIT } <br /> SANJOAQUINCOUNTV ENVIRONMENTAL HEALTH DEPARTMENT 9+ - <br /> NON-REFUNDABLE PERMIT CALL(209)9S3-7697 WR EAAVE3'IRES7ipYEARFROMCKTON CA D2-(2IISSUE.�Zp <br /> , EXPIRES YEAR FROM DATE ISSUED <br /> Joa ADDRESSA20 S 19" <br /> CIWIZIP <br /> CROSS STREET ML�pl, <br /> Is <br /> PARCEL Selz 2S1�ITIs <br /> OWNER NAME 20 <br /> _ A[LAND USE APPLICA710Kk�` <br /> OWNERADDRESS PA-E 269-CM-/s(ae) <br /> I C' <br /> S'TATPIZIP <br /> CONTRACI'OA <br /> PRONE zLR Z.,S4-0%ty <br /> —9-5=L— <br /> CONTRACTOR ADDRESSWES rJ •Z <br /> CITT1STATE/7.1P �S <br /> SUBCONTRACTOR <br /> P110KE 2,095 <br /> SUBCONTRACORADDRESS 23�� GJlC.ttd,�q�t L7y <br /> - C[TV/$TATE/TdP_5�L/� /a <br /> LICENSE C-57 O C-61 O D-01 o Other NUMBER 1 2 -��•S� V- <br /> EXPIRATION DATE Oj <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> INTENDED USE CI Darnenidprivate ❑Irri tonfA eullanl D Industrial Township Z S Range J Seetion-3 - nl <br /> aterQltelity Monitoring LI Soil v <br /> 1. Public Watts 5 SamplinglChsracterization <br /> IfdiRamrfrom= sar a� <br /> rax:w <br /> TYPE OF WORK iilew Well O Replattmcal Well CI WWI Alteration/Modification <br /> U Test Hole 0 Other <br /> XMonitoringWtll(s), I ofweils OSoilnoring(s) aafhovirw ex <br /> ❑Well Destruction O Geotechnical bOriaBr <br /> O Out-0f•Service Well O Gus-OF5ervicc Wdl Rettewa! <br /> ❑New Pum O Pum R ❑Pu it <br /> WELL CONSTAUCTIGN OCross�alneetion it <br /> Drilling <br /> hod <br /> ❑Mud Rola? Q Air Rotary Auger Q Cable Tool <br /> Proposed Well Depth Z$ Push Paint D Other <br /> 0P / R Excavation <br /> 0 Conductor Casing diameter ❑Open Bottom Q Gravel Pack/Gravel Sia in diameter <br /> in diin ameter / Conductor Casing Depth <br /> l Wel!Caring Diameter 2 In Thickaess/GaurJASTM Sc edp <br /> �` d Steel `Plastie O Stainless Steel ❑Outer <br /> Grant Seal Depthe5-110 _It 'Neat Cement(9I 1b bag/S-)0 gal xnrrr) []Sand Cement <br /> O Bcnionite(2o%solids) ❑ManufactuteT Spec%solids,% Name sack mix/7 gal water <br /> Grout Placement Method ❑Pum — d Specs on File [}Specs Submitted <br /> Pumped Frey Fall ❑Other ©Retardant/Accelerctor(name) <br /> FPEDWrAL 1p ailed By 'Driller OPump Contractor ❑Other <br /> Concrete Pedestal Dimensions: Width <br /> ��_ft Length 4�ft Thick 9 to <br /> 0 Submersible ❑Turbine 17 Other d Christy Ba= Stove Pips <br /> UmON p HP PUMP Set ft Standing Water Level ft <br /> Open Bottom ❑Gravel Pack d Uncoiled Q Other <br /> Well iNameter_in Tota!Depth R Depth to Wares ft ❑Casing to be Perforated front <br /> Seallog Material ❑Neat Cement(94 1b bag/J-!U gal water) O Sand Cement ft to ft <br /> sock mix/7 gal water 13 Bentonite Pellets <br /> ❑Bentonite(2014 solids) (3 Manufacturer Spa%solids�Y Name <br /> Ptacemenl Methal ❑Pumped O Free Fell Specs on Fie O Spas Submitted <br /> ❑Other <br /> 17 Complete with Mttahroom Cap R below grade CI Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN AEQ <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE REEIICEENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM[N ppp�M�y rT��-Aq,N- �y�q <br /> WORKERS COMPENSATION LAWS. C�U Atf Zan ALL <br /> MINIMUM 24��HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ��J j Zan <br /> SIG-MELlriaa, TITLE yp�� 7 DA11SAN JO OUIN COUIM <br /> fN b <br /> _ ..__ <br /> qP <br /> D£PARTMEN I ON <br /> AppFiuOdh"ted-B _ cc view" <br /> Grout Inspection By �� 1bN <br /> Date V 13 SPECIAL Well Permit <br /> Pump Inspection By Date_ 13 WAIVER Received <br /> Destruction Inspection By Gate <br /> Constructed Well Depth n <br /> COMMENTS r W <br /> 2 c � <br /> fa <br /> E SC Received Amount <br /> Codes InfoB <br /> Cash Remitted Date Permw Invoice Servkt Re nvo <br /> eat N Well IDp <br /> !r <br /> I <br /> MASTER WATER WFU PERMIT <br /> I <br />