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WELL /PUMP PERMIT — <br /> 304E WEB`.0've 311FL-STOOKItONCA95]0] - (]tIV)�aN-x410 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT\ .'CANE 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED ,�'� <br /> NON-REFUNDABLE PERMIT \� All � -.;Iy+�� y,_Cf ,67$LJ y <br /> 1 ITY/ZIP !S A l <br /> o Aos r+ �'l (¢ o <br /> JOB ADDRESS n —O J ev — PARCEL SIZE In <br /> ! APN 1' U 1 <br /> jj <br /> CROSS STREET ^ PIIONE ��•�� '���� <br /> 9FZ/L1 <br /> OWNER NAME ' ^ ^ 0 <br /> CI'fYISTATEI"LIP <br /> OWNERADDRESS IIONE � �f����- <br /> CONTRACTOR ' ^ <br /> CITY/STATFIZI <br /> CONTRACTOR ADDRESS <br /> PRONE <br /> SUBCONTRACTOR <br /> ITYISTATE/LIP <br /> SURCONTRACr AI 1: EXPIRATION DATE U <br /> -61 ❑D-09 ❑Other NUMee <br /> LICENSE C-57 Y Township _ Range Section <br /> GEOGRAPHICALINFORMA ION: Coordinates X <br /> INTENDED USE ClDomcstio/Pnvate ❑Irrigation/Agricultura1 ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characcenzalion <br /> ❑Public Water System onre o °r <br /> IfdiM.r1fr°m Owns: nor ysrem arae _- <br /> �: ,'gpther <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification number of nnlss numberofbunngs l'y <br /> numberofwells ❑Soil Boring(s) ❑Geotechnical <br /> ❑Monitoring Well(s) � <br /> 4ell Destruction <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ' <br /> ❑New Pum 0 Pump Replacement 0 Pump Repair ❑Cross-Connection Repair <br /> A <br /> WELL CONSTRUCTION <br /> Drilling Method I P Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth tt Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth Il <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gad water) ❑Sand Cement &e k rnir/7 gal water <br /> ✓_ <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> v <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other -1- <br /> 0 Concrete Pedestal Dimensions: Width R length Fl Thick in ❑Christy Box ❑Stove Pipe �Y <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tl Standing Water Level ft <br /> WELL DESTRUCTION pen Bottom ❑Gravel P}ek ❑Uncased ❑Other Beit <br /> WeII Diameter D 4/in Total Depth �� - tl Depth to Water tt ❑Casing to be Perfomted from ft to R f <br /> Sealing Material ❑Neal 0-- <br /> Scaling (94 Ib bag/5-10ga1 waw—ler) Sand Cement��enck mit 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(200/.solids) ❑Manufacturer Spec%s6lids - %% Name ❑Specs on File El Specs Submitted <br /> � <br /> Placement Method ❑Pumped ❑Free Fall Other / ��/f:Pfr! /jf- <br /> Nt'omplete with Mushroom Cap ft 6elow grade ❑ omplete to Existing Surface Pad <br /> 1 HEREBY cutriFY 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 /> MjNlMU OUR ADVANCE NOTIIRED GOR 1 SPECT QNti z <br /> SIGNED G ��—T,•rLe L� - ITE <br /> n r <br /> h <br /> i_ / <br /> Jc <br /> aJ. a�� o DEPARTMENT USE ONLY } <br /> Application Accepted By / Date S' 6— 03 Area Employee lD# Lp �•� <br /> Grow Inspection By Date <br /> ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date S onsIructed t II Depth ft <br /> COMMENTS <br /> PE- SC Amount Check#d Received Per <br /> Codes Info Remitted Cash By Date Service a Rest# Invoice# Well ID# <br /> EH D 43-02-006 <br /> snn_oo2 MASTER WATER WELL PERMIT <br />