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WELL / PUMP PERmrr SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DO—NTMENT 304 E WEBER 3""FL-STocxToN CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT t ALL, 209 953-7697 FOR INSPECTIONS � . API RES I YEAR FROM DATE ISSUED /� 4 2 !/ to Jon ADDRE59 � � ,� CITYlZ1P /I��s � / )��J-O� a + /�!]1�}DrEj Qppt APN PARCEL SIZE 1 V CROSS STREET � 1�1..— O?�'- �� O! QGZC-"r OWNER NAME /'f� 1' PIIONFtlo ! A96 �C.16,?r7 Q l� � O OWNER ADDRESS O C+ 1 )O CITVISTATEIZIP Q CONTRACTOR t Plto�nt: �/� t - / JS qff r CONTRACTOR ADDRESS � V C11-YISTATEIZIP S/{[JC+� b 064, SUBCONTRACPOR r! PHONE // SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / %/• ____ ' LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER I EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section .,. InTENDED USE aDomestic/Private ❑IrrigationlAgricuitural ❑Industrial ❑Water Quality Monitoring b Soil Sampling/Characterization ❑Public'Water System Vdifferent from owner: Winer System Name Contaci Nume or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other_ ,_„ ,1 ❑Monitoring Well(s) number of wells ❑Soil Boring(s) num6erof6orngc ❑Geotechnical nomberofbgrings i7. ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement rr -Pum`Re ai ❑Cross-Connection Repair > W ELL CONSTR UCPION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 1 Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth 11 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth It ❑Neat Cement(94 1b hug 15-10 bed wider) ❑Sand Cement suck mix 17 gal,waler 6 ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant!Accelerator(name) (j PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ' ' ❑Concrete Pedestal Dimensions: Width ti Length R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ,Other :� HP Pump Set "' D - tt Standing Water Level _ _3 ti ' WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth tt Depth to Water fl ❑Casing to be Perforated from 11 to R Sealing Material ❑Neal Cement(94 11)bug 1 S-10gu!wager) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(200A solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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 MY REQUIRED LICENSE 1S CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL, WORKERS COMPENSATION LAWS. MI>LDAUP V HOUR ADVANCE NOTICE RE J1RED FOR INSPECTIONS _- SIGNED4/&�-z T., /__ TITLE DATE oe I i A U ,Ft _ r NT 1 DEPARMMEi T--USE_ L �`_��. � ._ _ . Application Accepted By LLf� T Date � i U Area 2 C-' Employee ID# l S�" fq Grout Inspection B Date El SPECIAL Well Permit P Y Pump Inspection By Date ❑ WAIVER Received Destruction Inspectio B Date Constructed Well Depth It COM ENTS !� � 00 PE SC Amount Ctcck#1 Received Date Permit! Invoice# Well IDN-i Codes Info Remitted s By Service Request# 0 %-6 2� !�01 11 SRj 3�2-5 Eli 43-02.006 MASTER WATER WELL PERMIT i 517!2002 t 5