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SAN JOAQUIN Couwi,ENVIRONMENTAL HEAI.;t JWTARTntENT 304 E WV('-41VE 34"11),-STOCi(rc)N CA 95202 - (209)468-3420 "'NON-REFUNDABLE PERMIT �_ )951-7697 FOR 1:NSPl•:CTIONS - EXPIRES 1 YEAR FROM DA'Z'E ISSUED /��J 'f �y�r_ to JOB ADDRESS CITY/ZIP Ila d1 / �L�' /l �� CK1 -70117 CROSS STREET 1 n A L —/7D f � PARCEL$I'!.E � p OWNER NAME � �r1j Q I OWNER ADDRESS d V`_ �`1+ -1 - CITYISTATE ZIP CONTRACTOR dmsPHONE CONTRACTOR ADDRESS % CITYISTATE/ZIP SUBCONTRACTOR PHONE r„I SUBCONTRACTORADDRESSCITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System 1f different from Owner: Water System Name ontact ame or one um er TYPE OF WORK ❑New Well ❑Replacement Well Nell Alteration/Modification ❑Test Hole ❑Other ❑ b MonitoringWel I s number of wellss ❑ number of borings numer of bgorin ( } Soil Boring(s) ❑Gt•otechnicaf �` ❑Well Destruction ❑Out-Of-Service Well ❑Out-OFService;Well Renewal ❑New Pumn ❑Pump Replacement 0_Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 0 Other Grout Seal Depth ft ❑Neat Cement(94!h hug/5-10 gal water) ❑Sand Cement sack mix 17 gal water .❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed B ❑Driller ❑Pump Contractor *etherX . oncrete Pedestal Dimensions: Width L ft Length ft thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ©Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to It Sealing Material ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 0 Free Fall ❑Other ❑Complete with Mushroom(up It below grade ❑Complete to Fxisting Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN. COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MV REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS— PLEASE CALL(209)953-769 SIGNED �ti/.'VL- r��--:. Trrt.E L+ v !�", � Q Ve9,3 - DA'1'F: FF A TH ER ICF. EN 1IRC qMENTA Dlnyu LA F V JL ZZ DEPARTMENT USE tiLY Application,Accepted By ate Area _. Employee ID# ' " Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Dat e ❑ WAIVER Received Destruction Inspection BY Date Const tlted Well pth ft COMMENTS 7 PE SC Received Chec mount 'Date Permit! nvoice# Weil ID# Codes Info By Cash Remitted Service Re uest# 5 -7-7q o FHD43-02-006MAtifI <1 'I'IliWECLLPI;I{MI" 12l612[i[12 d