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I WELL/PUMP PERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HEDEPARTMENT 304E WEBER AVE 9°1pL CKTON CA 95202 -(209)46&3420 <br /> NON-REFUNDAB E PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIR1 TEAR FROM DATE ISSUED <br /> JOB ADDRESS In <br /> CITYIZIP — <br /> CROSS STREET :arx ---- <br /> OWNERNAME !1` L-,0119 CA'­"OWNER ADDRE417:�6 ='q5 O MATE/ZIP PfH/OeNaE C � <br /> 1*;.Ygp <br /> CONTRACTOR E PHONE f J.10 <br /> CONTRACTOR ADDRESS2080AJ.a P" <br /> ril U.l_ 'k- J CtTY1STATE7ZiP � r rl 15"47 L <br /> SUBCONTRACTOR lG G+t`i�- 1� i 1 Iylr� p f _ PHONE <br /> SVBCONTRACTORADDRESS A90A �n+1 a 6/o Ave CTrYWATE/ZIP -rte (141 15127 <br /> LICENSE 'KC-57 ❑C-6i 0 D-09 ❑Other ` NUMBER EXPIRATION DAIE - 66 <br /> GEOGRAPHICAL INFORMATION: COOrdinstes X V Township_ Range Section <br /> INTENDED USE 0 DomestiClPrivelc 0 IrrigaliordAgricultuml 0 Industrial. 0 Water Quality Moniwring )(Soil SamplinglCharaclerization <br /> ❑Public Water System <br /> If difr.—i from D� ata yssem amt COMKI Xomeo Phone NumWr <br /> TYPE OF WORK O New Well 0 Replacement Well ❑Well Alteralion(Modificatian 0 Test Hole 0 Other <br /> number arw ns umbrr oftodn n� Qol barinsr <br /> 0 Monitoring Well(s) *oil Boring(s)� �� q/J�/OJ •�Gablechn'scak <br /> C3 Well Destruction 0Out-0f-Service Well Vm 2r]hl,'4 Well Renewal <br /> ❑New Pump, ❑Pump Replacement 12 Pump,Repair 0 Cross-Connection Repair <br /> WELL CONSTRUCrION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary Auger 0 Cable Tool ❑Push Paint - ❑Other <br /> Proposed Well Depth (�!--� n Excavation in diameter 0 Open Bottom 0 Gravel Pack I Gravel Size in diamcler <br /> ❑Conductor Casing in diameter I Conductor Casing Depth 11 <br /> Well Casing Diameter_in Thickncs9GougcJASTM Sched C]Steel ❑Plastic 0 Stainless Steel 0Other <br /> Grout Seel Depth 11 ❑Neat Cement(941b hag 15.10 gal water) ❑Sand Cement sack mix 17 gal water <br /> 0 Bentonite(20°A solids) ❑Manufacturer Spec%solids_°/ Name ❑Specs on File El Specs Submitted <br /> Crout Placement Method ❑Pumped ❑Free Fall ❑Other O Retardant!Accelerator(aame) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor M Other C) <br /> ❑Concrete Pedestal Dimensions: Width_R Length_ft Thick in ❑Christy Box ❑Stove Pipe nl <br /> PUMP C]Submersible ❑Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION 13 Open Baltom ❑Gravel Pack 0 Uncased 0 Other - <br /> Well Diameter in Total Depth tt Depth tO Water R ❑Casing to be Perforated from R to ft 1` <br /> Scatting Material 'Neat Cement(941h bugl5-I01,al haler) ❑Sand Cement sack mix!7 gal water 0 Benlanitc Pellets <br /> 0 Bentonite(2(°/solids) ❑Manufacturer Spec%solids_% Name O Spore on File 0 Specs Submitted <br /> Placement Method 0 Pumped Free Pall ❑Other <br /> 0 Complete with Mushroom Cap, R below grade 0 Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN a <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 /> MI 1M OUR ADVANCE NOTICE REQUIRED/FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> DATE _ <br /> It <br /> at <br /> . A .7 '+ - <br /> ;,, s <br /> Application Accepted By - r Date Area 1 Employee ID# �i/' f 9� <br /> s i 1 Ctot}Y D .. <br /> Dare ZIL11[� ❑ SPECIAL Well Permit <br /> Pvmp[rsspcction By Y~ Date - ` ❑ WAIVER Received - <br /> Destruction Inspection By Date � Constructed Well Depth R <br /> p COMMENTS br`l}�drW i 6Cs C. •I/r.i1'.nA 2/Lf6St/m �W fr)�,YL{ <br /> PE SC Amount Check#/ Received Data Permit! Invoice# WeI11D# <br /> Codes Info Remitted Cash B Service Request M <br /> 41-7x- f -0 23c:-N-) 7 35 Y IL11urr 2 <br /> EHD43-02-006 MASTER WATER WELL PERMIT <br /> 517/2002 <br />