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L WELL/PUMP —ER" —TT SAN JO)NjBF:ON NVIRONMENT.1 HEALTH DEPARTMENT V I,BldE WEBER AVE 3-FL-STOCRTON CA 95202 -(289)468J426 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED N JOB ADDRESSN'I� J Vflner � C�IT/Y/ IP fZ � a/R fa a y PI Dyl 41 APN� ItlL'-- PARCEL 51zE 1. -I A ` CROSSSTREET (�A 7 ( GC OWNER NAM . Ort +/8��1 O1 /VA(10G1nKJ POONE OWNERADDRESB �yLyi sti j, CITY/STATFlLIP f CONTRACTOR {r R PIIONEe� /J COWEAcTORADDRESs Ct VISTATE/ZIP P✓ C Q SUBCONTRACTOR NIONE L L SUBCONTRACTORADDRESS CDY/StATEI IP LICENSE 4 -57 E:1 C-61 0D-09 ❑Other NuMBER EXPIRATION DATE /Uig GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Seetion `- bei (MENDED USErem,estic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Samplfng/Chanicteriumm E3 Public Water S= R 1fdOc tm al r ,,. .a. a.m., .m.m n< . r TYPEOF WORK ew Well O Replacement Well ❑Well AlsmtioN odificauon D Tesr Hale, ❑Other ❑Monitoring Well(s) nonxrd.dh pSoil Bming(s)_ omm otbo—,, ❑Geotechnical umuxeroflomp J ❑Well Destruction ❑Out-Of-Smitt Well 0Osis-0f-Service Well Rcncwal G O New Pernp ❑Pum R hcemcnt ❑Pu.p Repair O Cmss-Connectum Repair WELL CONSTRUCT(AM Drilling Method AMed Rotary Sir Rotary ❑Auger 13 Cable Tool ❑Push Point 13 Other V Bae Propmed Well Dcpth.�(ft Eacavmim in diameter ❑Open Bottom )<Gravel Pack/Gravel Sies_11 in diameter ..1 ❑CarWuctor Casing in diameter / Conductor Casing Depth It /�� t1 Well Casing Diameter nn Tnickmm,,Gaug.(ASTMSched 160 0S.1Plastic ❑Scum.Steel ❑Other # Grout Seal Dmth 0 ft ❑Neat Cemenl(941bbog/5-10ga1wmer) ❑Sand Cement .,.,*,A&/7gal under a _ 4—Bemonite(20°/.solids) ❑Manuficturo Spm%solids_%. Name ❑Specs on File ❑Spas Sulam and Grout Placement Method VPumped ❑Fra Fall E3 Other ❑Reardem/Accelmmr(name) PEDESTAL Installed By ❑Driller O Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length it Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submrsible ❑Turbine 13 Other HP Pump Sri ft Standing Water Level 8 WELLDESTRUCTION 13 Open Bottom ❑Gravel Pack ❑Uncased OOther Well Disman.r_in Total Depth ft Depth in Water R ❑Cuing to he Perforated from ft m ft Sealing Material ❑Nest Cement(94 th Mg/5-10 gut wafer) 13 Send Cement sock mor/7 gal worst O Bentonite Pellets ❑Bentonite(209:solids) ❑Manufacturer Spa%solids %. Name ❑Spas on Filc ❑Spas Submitted R.. Placement Method ❑Pumped ❑Fra Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 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. MINIMUM/24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED 1l I C. r s'1Q TITLE V s,1, /O.w DATE 11LIV MTY H w L P BU HE UH ER CE I DEPARTMENT USE ONLY L ApplicationAccepledBy V Aa - Date Q Qti Arm EmployalDN 1314 Grout Irepectmrs ✓ Dam OZ ❑ SPECIAL Well Permit L PumpinspmtionVVyDare ❑ WAIVERReceived Destruction InspatioIt By Dote Constructed Nell Depth R COMMENTS PE SC Amount Chec Received Dale Permit/ Invoicep Well ID# Cod. Info Remitted ash 8 Service Binaural# Bass 4366 V EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/.,002