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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H LAI TH DEPARTMENT 344 E WEBER AVE 3"FL-STOCKTON CA 95762 -(209)46g.3424 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTION$ EXPIRES I YEAR FROM DATE ISSUED <br /> s�� 1 e:tt,r/z1P F,e c, <br /> JOS ADDRESS � Y __�-C1_'L•�� <br /> / a <br /> CllOgdISTREET R .tom APN 2-Sz�UZU-- PQAR^c�r.LJsne 2/� <br /> OWNER NAME - rs 11[_L/ l -�! I P1110" <br /> OWNER ADDRESS <br /> 1 C ATS/7AP <br /> V" <br /> C.,pA.7. est � A. �} A�.�./' PRONE -•� it S/ <br /> C9NTRACTORAW"M -Be 1/r, r L e-,. Ate, f d � !J 7 C,TvISr'%TPMP �+ r <br /> SubcomrRAcrolk <br /> PIrDNe <br /> SuscowrRAcroR ADDRESS CITY/STATEMP <br /> LICENSE 17 C-57 O C-61 —[3"9 ha .' NVM3ERfjjP EXPIRATION DATE - / <br /> ' GEOGRAPHICAL INFORMATION: Coordinates X Y Tewashlp_ Rapge Section <br /> Irtsr,Nt1ED USE yeolneaticJPrNme C3ItrigalionfAgrienllunl a Industrial 13 waterQwliry Monitoring D 5oi15amplinglChamcicSation <br /> . /0 Public WarerSv�-tem <br /> Irdiltaent rmm Owner, yaam ante - pend or u <br /> Tvrx OF WORK O New Well Cl Replacement Well 0 Well AlhrmtioNWIodiRcation 0 Tal Hale O Other <br /> 13 Mom Wa Wella ewabaorw�eth nwnhuerbwhW aanrbnafbaiaq <br /> & () 13 Soil Boring(s) (]Geotechnical <br /> 0 Well Detraction O Out-0F-Service Well 0 Out-0&Service Well Renewal <br /> Q New Pum m Lqmct 0 N=itemi, 0 Croaa-Conm:C.ion Repanr <br /> WELL CoNsTRuLYtoN <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger O Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth R Eravation in diameter l]Open Bottom 0 Gravel Pack/Gravel Sia in diameter <br /> 0 Conducuw Caning in diameter I Conduc or Ctasing Depth R <br /> Well Caslne Diameter,in ThickneasifGaugdASTM Schad 0 Steel 0 Plastic 13 Stainku Steel O Other <br /> Crest Seal Depth R (3 Neat Cement(pI lb bug/3-/O gal w44r) O Send Cement rwcfr mirf 7 pi water 01V <br /> j0 Bentonite(210.6 solids) 0 Manatitriurer Spec%solids % Name 0 5 <br /> person File OSpeesSubmided <br /> Growl Placerne„t Method 0 Pumped L7 Free Pall OOthcr 0 Rciardant/Acaelarator(name) <br /> PEDESTAL Intalled By ©[)tiller D Pump Conlrnctor 0Other OC <br /> 13 Concrete Pedenel Dlmentlenst Width--fl Length R 111iek iD 0 Ckslsly BOX Q Stave Pipe <br /> PUMP ubMefdbk 0 Turbine Q Other HP r Pump Sm__LW it Standing Water Level A26 fI <br /> WELL DESTRUCTION 130pen Botlprn 13 Graved Pack O Untried D Other F.. <br /> Well Diamerw in Total Depth R Depth to Water R 13 Casing to be Perlinted from R to R <br /> Sealing Material a Nat Ca hent(W 1b bag/J.10&w;water) 0 Sand CCMflL mac*Antr/7 pl water O Balonite Pellw <br /> 0 Bentonite(2491 solids) 0 Manu recturer Spw%solids__% Name O Specs on File 13 Spee Submitted S� <br /> Placement Marked 0 Pumped El Free Fall 0 Other_ (� <br /> C3 Complete with Mushroom R bckm,grade O Complete to Existing Surrue Pad <br /> I HEREBY CERTIFY 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 RIF:GULATION& 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN TION LAWS, <br /> MlfSTtI�HOUR ADVANCE NOTICE REQ RED FOR INSPECTIONS <br /> s�GNen TrrLE DATE <br /> AA <br /> at J <br /> DEPARTMENT USE ON Y <br /> Application Accepted By _ Date Area ��1c+ Employee IDM s{'S 349 <br /> Grout Inspection Bypale fl SPECIAL Well Permit <br /> l Pump IruPtztion By Dare O WAIVER Received <br /> i Destruction Inswtion By Date Constructed Well Depth_ n <br /> COMMENTS <br /> PE SC Amount Ch Received Permit! <br /> Cadea Info Remitted C�asrh 8 Date racy * IDSoke M well 100181 ,til,} ! L-1J Q-7 <br /> 2-066 <br /> "/2002 MASTER WATER WELL PERMIT <br /> 517f2002 <br />