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WLI;LL / YUIVIY YL+mV111, — <br /> SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH♦♦- DARTMENT Nu <br /> 304 E WEB vE 3 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT _CALL 209/7953-7697 FOR INSPECTIONS "XPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS I S �+� +�--19 <br /> CITYIZIP <br /> a y <br /> CROSS STREET h-•/' APN C-573'Cz <br /> /i�- <br /> J j [ — SZ- V PARCEL <br /> Ir <br /> OWNER NAME L C-✓trite <br /> PHONE V <br /> Is- <br /> OWNER ADDRESS }� CITY/STATE/ZIP <br /> CONTRACTORV " � (� r <br /> J PH ON �� c+ <br /> CONTRACTOR ADDRESS V i' CITY/STATE/ZIP n <br /> 1111 <br /> r SUBCONTRACTOR P O <br /> L <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �Z-57 ❑C-61 ❑D-09 ❑Other NUMBER 7-7?5 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rangc section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Irdifrcrent from Owner: Watcr.System Name ontact Name or Phone Number <br /> TYPE OF WORK>rNew Welt ❑Replacement Well .❑Well Alteration/Modification ❑Test Hole ❑Other <br /> lU Monitorin Well 5 numberofwells numberorborings <br /> g 11Soil Boring(s) E3 Geotechnical number of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> A140—w Pump ❑Pum Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCT[ON" <br /> Drilling Method >Iviud Rotary Cl Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ether <br /> Proposed Well Depth 3 UO tt Excavation in diameter ❑Open Bottoms rave]Pack/Gravel Size in diameter <br /> ❑Conductor asing ut diameter / <br /> Conductor Casin epth tt <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched7 h� 13 Steel Plastic C3 Stainless Steel ❑Other <br /> Grout Seal Depth ��y� ft ❑Neat Cement(941h bag r/5-10 gal wider <br /> —e`—�— ) and Cement <br /> —spas �t✓ suck mir 17 gal water <br /> 13 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method umped ❑Free Fal] ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By y�216riller ❑Pump Contractor ❑Other <br /> >dcontrete Pedestal Dimensions: Width tt Length ti Thick�— in ❑Chr.isty Box ❑Stove Pipe <br /> PUMA ubmersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel-Pack ❑Uncased ❑Other <br /> We]I Diameter in Tota]Depth ft Depth to Water fl ❑Casing to be Perforated from tt to fl <br /> Sealing Material ❑Neat Cement(94 Ih hug/5-10 gal water) ❑Sand Cement sack mu 17 gal water ❑Bentonite Pellets - <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs oil File ❑Specs Submitted 2 <br /> Placement Method ❑Pumped ❑Free Fal] ❑Other <br /> ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad <br /> 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. I 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 /> NIMUM 24 FLOUR ADVANCE NOTICE <br /> ^jRE- `QUIRED FOR INSPECTIONS <br /> SIGNED ` 1 TITLE `� w DACE g—[per07 <br /> } <br /> er <br /> F <br /> --SAN A UI C U <br /> EN lH DN E A <br /> fj <br /> tion Ac4 epted By Date �—� � <br /> Area 4' Y Emp o ee9k l/ <br /> Grout Ins coon . /Cf!/ <br /> y Date_ �/��,�/ . ❑ SPECIAL Well Permit / <br /> Pump Ins coon By Dat&� •gyp L,/ ❑ WAIVER Received # <br /> Destruction Inspect♦ y <br /> Date Constructed Well Depth ft <br /> COMMENTS d <br /> PE Sc Amount Che Received rmit/ <br /> Codes Info Remitted ash By 4F�P <br /> Re uest# Invoice# Well 10# <br /> � 3� <br /> EHD 43-02-006 <br /> 5/7!2002 MASTER WATER.WEL,I.PERMIT <br /> y <br />