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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL F(r+c�7H DEPARTMENT !!!( '}! 3pgEWESERAVE3�7''riroCKTONCA9 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS * EXPIi, [ YEAR FRo a4a r— E ' JOB ADDRESS ��.++ Cy �•�•�x 1 o CtTv21P_ �C��r� ROSq STREET ��w.r�•l R'C /� f p f OWNER NAME Z�ra PARCELSIZE 1 "��+- OWNER ADDRESS 51c PHONE d d 1�0 rrY1SrATE1ZIP_f SeAY 1 CA -141 CONTRACTOR +� PHONE 06to CONTRACTOR ADDREMM b$f> 1 'T�C, BLV" g CITYISrATFJZIP f, CA • 53 6 SU$CONTRACTOR GS` �Ti 1✓1 PIIONE SUBCONTRACTOR ADDRESS_ r so CITY/STATEIZIP CA L,eENSE a-57 13c-61 q DI ❑Other ' NUMBER S Q ExPIRATION DATE CEOGRAPFUCALINFORMATION: Coordinates X l• INTENDED USE ❑DomestiCiprivaleTownship Range Section ❑IrrigationlAgnC4IItural ❑Industrial ❑Water Quality Monitorin ❑Public Water S S X Soil Sampling/Characlerization if diffmrt from i�r. ntt yncm rme nese, eme ar um TYPE OF WORK M New Well E3 Replacement Well O Well AlteretioNMadificalion ❑Test Hole ❑Monitorin Wells numLerorwelh Ill{O[her CPT y g (} ❑Soil Boring,) rwmbernfborinp �CGealxhnical nurr6c of baring /�• CT 13 Well Destruction ❑Out-Of-Servjce Wel! ❑QUI-Or-Service Well Renewal New Porn q PumpR lacemrnt ❑Pum Re air WELL CONSTRUCTION ❑Cross�'onnectionR it Drilling Melhod ❑Mud Rotary q Air Rotary ❑Auger ❑Cable Tool bush Point q Other Proposed Well Depth 3 a—SO ft Excavation in diameter ❑ ❑Conductor Casin Open Bottom ❑Gravel Pack/Gravel Size in diameter 8 in diameter / Conductor Casing Depth� It Well Casing Diameter in Thickness/Gauge/ASTM Sched Grout Seal Depth [3 Site) ❑Plastic q Stainless Steel q Other DeP ft q Nee[Cement(94 Ahab/S-70gu1»nlrrf ❑Sand Cement ❑Bentonite(20%solids) El Manufacturer Spec%Solids«% Name ruck mix/7 gel Water ['q Grout Placement Method 0 Pumped O Free Poll q Other _ q Specs on File L2 Specs Submitted —rt PEDESTAL n f7 Relardent/Accelcrator(name) *t�� I B D Driller O Pump Cartrncror ❑Other f.. ❑Concrete Pedestal Dimension: Widths__g Length y 1 PUMP q Submersible D Turbine g R Thick in ❑Christy Bax q Stare Pipe ❑Other WELL Dt7'pUCTIDN l7 Urtca3HtdP =::I ft Standing Water Level eft ❑Open Bottom q Gravel Pack R Well Diameter - _,�in Total Depth ftDepthbWater to be Perforated from R to SealingMaterial Meat Cement(941h hag/S-1 Dgul uxrrerl q Sand Cement R 17BComnite(20%solids) 13 Manufacturer Spec%solids °/. Nl water ❑Hentonite Pellets -Placement Method 1]Pumped ❑Free Fall ❑Specs On File ❑Specs Submitted)Mher Trt�trrftbelowgrade1HEREBY CERTIPY Existing SurF'ace Pad -$= THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN �\ CURRENT N COUNTY ORDINANCES STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE N v CURRENT AND ACTIVE WITH THE CALIF LAWS, CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW& 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE � a5 �� DATE -AIA-4t z R Application Accepted By. Date1 G - , Ates •,�'r� Employee ID# j Y ._Grout Inspection By„1i fdw}-,.,e_ Date cig E"` � - -- PECIAL Well Permit I + Pump Inspection By Date - — ❑ S- - r WAIVER Received Destruction Inspection By �r Date Constructed Well Depth�`R COMMENTS .S @.yL� t1 D b J 9 ? PE SC Amount 6u Checld7! Received Codes Info Remitted Cashg Date Permit/ Invoice# 3-'72— JPO 2u OL 7�✓ �} Service uestM WelI1DA! .I •ta 3d' �f EHD a3-02-006 5/721102 MASTER WATER WELL PERMIT