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WELL/PUMP PERMIT SAN JOAQUIN CO(IN'rV ENVIRONML:N'rAl.HEALTH DEPARTMENT 304 E WERER AvE JMO FI.-Sr(ICKToN CA 95202 "09)468-3420 NON-REFUNDABLE PERMIT CALL[ 209) 7697 FOR INSPECTIONS EXPIRES I YEAR FROM ISSUED JOB ADDRESS S`7 / yV `/�u�-T(/ R�1 ( IV /� 1) /�/J /' CITY/ZIPZjl!��P r7Y CROSSSTREET ✓C// (r C I1/ (/"t/Z N PN 2S O 7ARCEL SIZE f Q p w OWNER NAME RAID AM PI{ONE OWNF.RADDRESS sAM E, CITY/STATE/ZIP .�AN%� CONTRACTOR SAS AJ /,J(/(.l PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PRONE SUBCONTRACTOR ADDRESS CITY/STATFJZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Id Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner. Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole Other-PE VSTKL-4"A*2r xgAr5/ ❑Monitoring Well(s) numberof—Els (3 Soil Boring(s) numberofbodngs ❑Geotechnical numberefbodngs 6A.51A&- ❑Well Destruction ❑Out-OfService Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth_ Il Excavation_ in diameter ❑Open Hutton) ❑Gravel Pack/(iravcl Size__ _in diameter pn ❑Conductor Casing_----_ in diameter / Conductor Casing Depth.-------- ___ 11 /„U Well Casing Diameter___.-in Ilticknesx/Gauge/ASTM Sched_____-_____ ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth Il ❑Neat Cement(94/b Ixrg/5-/0 gal wafer) ❑Sand Cement .tuck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) n PEnVS'I'AI. Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal III cuslons: Width__ _ Il Length Il 'thick _ in ❑Christy Ito% O Stove Pipe PUMP ❑Suhnier.,61c ❑Turbine OOther _ IIP__.___ Purup Set_. _ Il Slauding Wafer l.evcl WELL.DESTRUCTION ❑Open Ilouorn ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth R Depth to Water Il ❑Casing to be Perforated from Il to Il f� Sealing Material ❑Neal Cement(94/b hag/5-/0ga/wirer) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets (. ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other I�lfl ❑Complete with Mushroom Cap R 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 IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE. BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. EMU 24 HOU ADV N NOTICE REQUIRED<:OR NSL/p�`P�Ep,CTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE iC T DATE 3 oy EN IR DN VEII,TAI. ( 'EPA Application Accepted By r Date Area z/to Employee ID# "65 S Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By G7 Date ❑ WAIVER Received I)<:SlMmell0l I lion Ely_ Dale_ Constructed Well Depth if COMEN7 /�-— 6306 /32 C PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# - Codes Info By Cash Remitted Service Request# x.02 31-511--Lj&L25-70q2-- 1:11 D f LFIID 41-02-006 MASTER WATER WELL PERMIT J