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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"°FL-STOCETON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT / ``^^^^ CCJALL209)9'53-7697 FOR INSPECTIONS EXXP�PIRES��I YEAR FROM DATE ISSUED 3 JOBADDRFSS 17,7, "// J ._kY�(J�eY IL(1 a� CITY/ZIP�_$ Oy�l 45!V1 y LCROSS STREET JC/ANGY41 r e'11CY L PARCELSIEE OWNER NAME Ir-pefI /UtOGIcktof PHONE� W OWNERADORS04FV—? L - 9. bq CRY/STATEQZIP ` �r COMMCPOR elf K PHONEd COM"MCTOR ADDRESS CITY/$TATFIZIP .1 L SUBCONTRACTOR POONE G SUBCONTRACTOR ADDRESS COT/STATFILIP LICENSE C-57 ❑c61 0D-09 ❑Other NUMBER EXPIRATION DATE G L GEOCRAPHICALINFORMATION: CoordMales X Y Township Range_ Section_ INTENDED USE Domeshdprivate ❑In gutioNAgdaulmral ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/ChanctmLlien L ❑Public Water S In I— He�lr tram .- roam Nam Corract Homo or Phow N—loo L TYPE OF WORK ew Well ❑R'llo'clocon Well ❑Well Allerawn/Modificamm ❑Test Hole 13 Other — eerorwol[ v orWriny ❑Monitoring Wells) num ❑Soil Borings) roonvoarMnngi ❑Geotechnical nume ❑Well Destruction ❑Out-Of--Service Well ❑Out-0f-Service Weil Renewal C [3 New Pump 0 Pump R laumcm 0 Pump Repair ❑CmssConncnion Repair L WELLCONSTRUrn N Drilling Method 5KMud Rout, Air Be., ❑Auger ❑Cable Tool Cl Push Point ❑Other 0 Proposed Well Depth .0 _ft Excavation in diameter ❑Open Bottom Gravel Peck/Gravel Simian divaeer iM n ❑Conductor Casing in diameter / Conductor Cuing Depth �A ti orel �S+ Well Cning Diameter n ThickEEEdGauge/ASTMSchW ❑Steel kettle ❑Stainless S ❑Other L Grout Seal Depth 1.,R ❑Nut Cement(94 th Aug15-10 gal tooter) v❑`Send Cemrnl sad rales/7 gel wear d �O—Bentonuc(2Wo solids) ❑Manufactures Spee%solids % Neme ❑Specs on File ❑Spees Submitted Grout Placement Method umsd ❑Fru Full 13 Other ❑ReuNent/Accdmtor(name) PEDESTAL Installed By ❑Driller Cl Pump Contractor ❑Other L ❑Concrete Pedestal Da tamed..•. Width_B Length_R Thick in ❑Christy Box ❑Stove Pipe Pump ❑Submersible ❑Turbine ❑Other TIP Pump Set fi Sanding Water Level R WELL DESTRUCTION OOpen Bottom ❑Gravel Peck ❑Unused ❑Other Well Diameter_in Toal DE Hh R Depth w Warer R ❑Cuing to be Perforated fem ft to —ft L Sealing Material ❑Nur Cement(941h hug/5-10 gen/water) ❑Send Cement sackma/7 gal water ❑Remoni¢Pellea ❑Bentonite(20%sohds) ❑Manufecnmu SpEe%solida % Neme ❑Spees on File ❑Specs SubmaHcd Placement Method ❑Pumped ❑Fru Fell ❑Other ❑Complete with Mushmom Cep R below grade ❑Complete to Existing Surface Pad L 1 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. 1 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. L 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Slcn.D JL yr / TITLE V i t(� DATE I ey L L rw LDAVPAr NI L P BLI HE TH ER CE LDEPARTMENT USE ONLY Application Accepted By `r- - Data Q Area 218 Employee im 93-74- G t 3l4- Grout Inspection B Date OZ ❑ SPECIAL Well Permit L Pump lnspmtion y Dee ❑ WAIVERReceived Destruction Inspection By Date Constructed Well Depth R COMMENTS PE SC Amount Ch. Received Date es'Ro Invoice Es We111DX L Codes Info Remained ash B Service Re uestg 43 0 -225' / a a Roo3 LEHD43-0Z-006 MASTER WATER WELL PERMIT 5nnoo2