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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUVT-V ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3e"FL-SrocK'roN CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9P-7697 FOR INSPECTIONS EXPIRES l YEAR FROM TF.ISSUED <br /> JOB ADDRESS CITY/ZIP C n' <br /> CROSSSTREET �uQ- r r mss_JyO- O/ �3' f LAND USE aA <br /> ION0 p <br /> •"f APN PARCEI.517.F.��. <br /> OWNER NAME 1 PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRA M. )R C ` 0%4\ PHONE <br /> CONTRACTOR ADURESS CITY/STATEIZIP K-J <br /> SUBCONTRACrOIt - PHONE: <br /> SUBCONTRACFOR ADDRESSCITYISTATE/ZIP <br /> LICENSE. ❑C-57 C2C•61 O D-09 AkOther UQ NUMBER ExPIRAT1oN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X 1' Towoshlp Range Section_ <br /> rDEDusE mestic/Pnvate ❑Irrigation-'Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplingiCharactenzanon <br /> O Public Water System _ <br /> IfdiRerrn:fmm Uwner. aur ysum ameCAnUc,t Name or Phone N,mber <br /> TYPE OF WORK>'Aew Well ❑Replacement Well ❑Well Alterslion/Modifrcation 13 Test Ilole 13 Other <br /> ❑_Monitoring Well(s) p of wells ❑Sud Boring(s) r of bo•mss ❑Geouxhmcal _a of bormp <br /> ❑Well Destruction ❑Out-Of-Service Well O Out-0f-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair O Cross-(:onncction Repair <br /> WELL CONST'RCCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other_ / <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom Cl Gravel Pack/Gravel Sim in diameter W <br /> ❑Conductor Casing in diameter / Conductor Casing Depth If <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad`__ _ __ O Steel O Plastic O Stumless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(94 I6 hag/5-10 gal watrr) ❑Send Cement sack mix/7 gal Water ~ <br /> O Bentonite(20%sobds) ❑Manufacturer Spec%solids % Name ❑Specs on File O Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall O Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed BY ❑Driller O Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_R length_h Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP .)ErSubmcrsihlc ❑Turbine ❑Other ___ HP Pump Set-21CVR Standing Water Level fl <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased O Other <br /> Well Diameter_in Total Depth ft Depth w Water R ❑Casmg to be Perforated from R to fl <br /> Sealing Material ❑Neat Cement(941A hag/5-10 gal..ter) ❑Sand Cement sack mix i 7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name O Specs on File O Specs Submitted O <br /> Placement Method ❑Pumped O Free Fall ❑Other <br /> ❑Complete with Mushroom Cap__ _ ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> J(IAQITN COUNTY ORDINANCES.STATE LAWS.AND RALES AND REGULATIONS. I ALSO CF.R7lFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTU'E_ IT FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS AW'S. <br /> f- HOER ADVANCE NOTICE UIRF,D FO INSPF TIONS U <br /> SIGNED TITLE DATE og , O f <br /> VVI -11 <br /> 9 <br /> It <br /> lY <br /> 44 <br /> to <br /> {V <br /> DEPARTMENT USE PNLY <br /> Application Accepted By Dale Area "-f 6n Employee IDN 4`SE' 9 <br /> Grout Inspection By Date 13 SPECIAL Well Permit <br /> p <br /> Pump Inspection By __-. ._ _ ..- Date, f 1A a_ 0 WAIVER Received <br /> Destruction Inspection By _ _ _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Cfire Amount Date Permit/ InvolceN Well ID0 <br /> Codes Infa B Cash Remltt Service Request l7 <br /> lAwk VOL <br /> _� <br /> (f3Pu Od(j) St•u w O -Z 8- <br /> EHD43.024M MASTER WATER WELL PERMIT <br /> I L22?003 <br />