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WELL/PUMP PERMIT <br /> SAN JOA-QuiN.Coum ENVIRONMENTAL HEALTH DEPARTMENT 304E WEaER AVE 3-FL-STOCKTON CA 95203-(209)468-3420 <br /> .NON-REFUNDABLE PPERMIT �+ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATb ISSUEM <br /> JOaADORg83 I�r3 cr CITY21Pr?t .4 � <br /> CROSSME. rotti L.9 APN -(!'1—l —02 !6 <br /> PARCEL SIZE 1. O <br /> GwNERNAE _rC� Ilnn <br /> MTiWIC.rT�r�Y_ ..w� :4S PHONE r f7 �_ <br /> OWNIRADDRESS 3,'2j_-. f fA,[.r I'd, 5�114 A CITYMATFIZIP--R. .. i CA <br /> CON �� G r- <br /> i'RAC7'OA ! r PHONE � <br /> aulk <br /> CON4RAcTOR ADDRESS y�a O e r' * SLI.' =c.T.,,,.rwz,P 4,4 c 166206 <br /> SUttc`ONrRAcroR S PHONE Z24 ` LI&—A 717- <br /> SUBCONTRACTORADDRESS 6 Loi /-., Crry/STATEMP ia 4veju., <br /> LICENSE bG57 0 C-61 0 D•09 D Other NUMBER <br /> El 226 IT ExPIRATION DATE 3"OI/7aLt7 <br /> 3 <br /> GEOGRAPHICAL INFORMATION; Coordinate! X Y Township^_ RanKe Section <br /> INTENDED USE 0 Domettic/Private .0 Irrigation/Agricultural 13 Industrial 0 Water Quality Monitoring 0 Soil SamplinglChamcterizationCo <br /> _ O Public Water Syys5tem - <br /> _IfditrerrntfromOwnu: run tem o" .. L�wtgt Nemew um <br /> TYPE OF WORK 0 New Well O Replacement Well O Well Alteration/Modificstion 0 Test Hole O Other <br /> ❑Monilorirt Wellwmbrr0"Its aamberufbort <br /> $ (a) Z3 Soil Borings) °ar OGeotechnical wmav arherinlp <br /> ) 1Ve11 Destruction pyo /'1 n,) (]Out-0FService Well 0Out-Of-Service Well Renewal <br /> New Pum 0 m R lacement 0 Pump R itOCross-Connection R it <br /> WELL CONSTRUCTION <br /> Dr1llIn=Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool O Push Point 13 Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Grovel pack 1 Grave]Size in diameter <br /> Cl Conductor Casing in diameter 1 Conductor Cuing Depth ft <br /> Weil Caslag Diameter_in Thicktt=dG@ugdASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Otber <br /> Crout Seal Depth ft d Neat Cement(941b!wg/J-10gal wuter) O Sand Cement rack m& 7 gat water <br /> 0 Bentonite(20r/s solids) 0 Manufacturer Spec%solids_% Name 0 Specs of File 0 Specs Submitted <br /> Grout Placement Method 0 Pumped. 0 Fre Fal! 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL initalltg 13r 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimension!: Width ft Length R Thick in 0 Christy Bax 0 Stave Pipe <br /> Pump 0 Submersible 0 Turbine 0 Other HP Pump Sel ft Standing Water Level R <br /> WELL DE MICTION 0Bottom 0 OmavW peck 0 Uncased 13Qtber <br /> Well Diameter in Total Depth / R Depth to Wafer*- 'S 'I D Casingto be Perforated From_5 R w n <br /> Sealing Material KNeat Cement(941h hug/5-10VI aver) Cl Sand Cement nock mtz/7 gal wafer D Bentonite Pellets <br /> 0 Bentonite(20%solids) D Manu[scturcr Spee%solids-T,_% Name 0 Specs on File 0 Specs Submiped ' <br /> Placement Method O�Pumped 0 Free Fall 0 Other <br /> 0 Complete with Mushroom Cep R below We 0 Complete to Existing Surface Pad <br /> I 1 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 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 /> M IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> GN <br /> SIED_�� Ttl'L8INt <br /> fi.1"I biA 1 pATC �1 ZI*�1 <br /> eej <br /> i 1 <br /> Appiikesti Accepted By Date_.6— -4 EQ Area I Efmpla�I D# <br /> _GroutInspection By _Date EL- SPECIAL Well Perm_E_t_ <br /> Pump Inspection By _- Date 0 WAIVER Received — <br /> Destruction Inspection By Date G �� <br /> COMMENTS_ Constructed Well Depth ft�/ <br /> PE SC Amount Ch 1 Received Permit <br /> Codes Info Remitted Co. B Date Srrvim nestlt Invoice Weil IDN <br /> ��3 � I S 0034035 <br /> EHD 43-02-006 <br /> 5/7/2902 MASTER WATER WELL PERMIT <br />