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WEL /PUMP PERMIT <br /> ' SANOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 0/ 304 E WEBER AVE 39°FL-STOCKTON CA 95202 -(209)469-34W <br /> NON-REFUNDABLE PERMIT CALL 2 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> .l <br /> JOBADDRESS 'Z3>47- Ali (AJUIT AJ � � PCi� A"=g2k� C11211 <br /> CROSS STREET S APN Z a i E'l`l G Z- 1 PARCEL SIZE /�- 4-C- Li <br /> OWNER NAME PHONE <br /> OWNER ADDRESS % r.4 I/ - - CITY/STATEMP (�I <br /> CONritACrOR PHONE '1 <br /> CONTRACTOR ADDRESS <br /> Crry/STATEMP ` I <br /> SUBCONTRACTOR09 <br /> SUBCONTRACTOR ADDRESS ZO �S - �YI.1 �'Z CrTY/SrATEZP s <br /> LICENSE C-57 ❑Cfil 0 0-09 0 Other NDMIIER 4f Z S Z-- EXPIRATION DATE <br /> C <br /> GEOGRAPHICAL INFORMATION: Caordlrotes X Y Township Range $ectba <br /> INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Chan <br /> 0 Public Water Systemo„�I „ <br /> If ddrarta Dom Q—. na* rte"' '"• <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole O Otherg tai twrn <br /> OMonitonng Wdl(s) mo <br /> n-beweli. Soil Boring(,) y aualer�aor+ap OGeatechnial � <br /> 0 Well Destruction 0Out-0r--Service Well 0Out-0f-Service Well Renewal <br /> 0 Ncw Pump 0 Pum R iacemtm O Pump Repair 0 Cross-Connection R it <br /> -41011111111L CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air RotaryAugcr ❑Cable Tool Push Point 0 Other <br /> Proposed .l-Depth fl Excavation4-1-sin dumeter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Cuing Depth 11 <br /> Well Casing Diameter_in Thicknas/Gauge/ASTM Sched 0 Steel 0 Plutic 0 Stainless Steel Cl Other <br /> Grout Seal Depth R 0 Neat Cement(94 lb bag/5-10 gal IvUleO 0 Sand Cement .rack mir/7 gal water <br /> 0 Bentonite(209/.solids) 0 Manufacturer Spec%solids_% Name 0 Spas on File 0 Spas Submitted <br /> Grout PLeemni Method 0 Pumped 0 Free Fall 0 Other 0 Retardant I Accelerator(rums) <br /> PEDESTAL Iastallod BY 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Diawnslons: Width It Length fl Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other <br /> HP Pump Sett ft Standing Water Level Il <br /> isom DESrRUCTION ❑Open Bottom 0 Gravel Pack 0 Unnased 0 Other <br /> Well Diameter_in Taal Depth A, Depth to Water R 0 Cuing to be Pertorat from ft to S <br /> SeoHng Material Neat Cement(94 Ih hag 15-10 gal esu er)E�0 Stud Ccmpu roc}ma/7 gal ester Bentonite Pellets CfF .10 py <br /> 0 Bentonite(209:solids) 0 Manufacturer Spec'/.solids_% Name 0 Specs on File 0 Spei suorm..ce <br /> Placement Method 0 Pumped 0 Free Fall 0 Other <br /> 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY VE1I DA CERTIFY REQUIRED THAT My LICENSE <br /> CURRENT AND AC7WITH THE CALIFORNIACAL FORNIA CONTRACTORS STATE NSE BOARD THI AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW <br /> ?4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS "Z— <br /> TITLE r��'V'��IIS 1j� DATE <br /> SIGNED <br /> J <br /> S N <br /> �- -- Date Z• �,Arn Employee 17_ <br /> Application Accepted - `vvy <br /> Grwt Inspection y Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Date Constructed Well Depth ft <br /> Destruction Inspec, y (] ry <br /> COMMENTS <br /> PE SC Arnouot hec Received Permit/ Iavokc Well IDA <br /> Date Service R uest A <br /> Codes Into Remitted sh By <br /> 2- <br /> S71 <br /> EHD 43-02-006 t �""w Yi MASTER WATER WELL PERMIT' <br /> snn_oo2 <br />