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�^,'srawx�*�^r <br /> h <br /> W+LI /PUMPP `sm <br /> SAN JOAQUIlyfi'VIRONfENTA(,1JEAL7'H DEPgR"1',afENT �PMT1 '� mT <br /> NON-REFUNN�E PERMIT _` 104 E WEBERAVE3 FL_ <br /> CALL(209)953-7697 rOR IN S'tOCKTON CA 95202 -(209)468-3420. <br /> JOBADDRESS ,i'rCS SVTION'S - EXPIRES 1 YEAR FRAM DATE ISSUED <br /> ^ CITY/ZIPry'/ ^.r` <br /> CROSS STREET /f%E t}�(< �. J N ir✓ S W U <br /> APN1 — y Y <br /> OWNERNAME t?, ''� J' (IJ F —Z-41- � PARCEL SIZE !• �(•f o <br /> �/ 5r� <br /> OWNERADDRESS � " PIIONZ5f <br /> / \ J CITY/STATE/ .,/� '-/"'r/'�l,G/r ' /) <br /> CONTRACTORr5 yPHONE o�^e''!.)/ 7 <br /> CONTRACTOR ADDRESS/ `J y�Z/t,(% T K _ y1� <br /> SUBCONTRACTOR �We`-(- <br /> r`J1,(- (y/2 <br /> SUBCONTRACTORADDRESS ,T C3 1 [.'T/.1e"(v"f2q- "—� �!'� ,-ICr ,y� �"�_ J���J•t-I. <br /> Crry/STATE/ZIP J <br /> LICENSE X C-57 ❑C-61 ❑D-09 ❑Other <br /> NUMBER 5r2 Ly <br /> EXPIRATION DATE �C J 3 <br /> GEOGRAPHICAL INFORMATION: CoordinatesRange ` S. X Y Townshirp_ ection <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitor,ing ❑Soil Sampling/Characterization <br /> ❑.Public Water System <br /> - 4� <br /> If different from Owner: mer ysrem ame onmcr ante or one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> numberofwellz numberofborings I nuniberofborings <br /> ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical <br /> Well Destruction YOut-Of-Service WeR.1, ❑Out-Of-Service Well Renewal <br /> - - - 0 New-Pure -- ❑-Pum -Re lacemenr---C1 Pump Repair ❑_Cross-Connection_Repair l <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Crave]Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth tY <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 11 ❑Neat Cement(94 1b hag/5-10 gal water) ❑Sand Cement sack fni.v/7 gal water <br /> ❑Bentonite(20%solids) ,ny ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> r <br /> ❑Concrete Pedestal Dimensions: Width_it Length_ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP _ ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ..8. o� <br /> _B <br /> WELL DESTRUCTION ❑�pe�BgttQm �G vel �clk .�.Q❑Uncased Other <br /> lI /!YY c'�1 tP t <br /> e Well Diameter 1/ }n Tonl Depth ft De th to Water ft Casing to be Perforated from ti to tcl' <br /> Sealing Material ❑Neat Cement(941h hag/5-10g'I water) and Cement rack mix/7 gal water ❑BentonYt ets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap tt below grade omplete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT [,HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED <br /> /FOR,INSPECTIONS <br /> SIGNED ""..� TITLE <br /> ��ji� T' l3 r`t' DATE <br /> r <br /> t <br /> J <br /> 1 <br /> mo- <br /> ' EN IR M TA. HE LTH IVI <br /> / DEPARTNIENT S ON�Y <br /> ..__ Date )....`. <br /> Application A Area 4 Employee ID# <br /> epted By ,(y�`Yrr- > ' � <br /> Grout Inspection By II��� Date _ ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth - ft <br /> COMMENTS <br /> PE SC Amount Isle/ Received Date Permit/ Invoice# Well IDN <br /> Codes Info Remitted Cash BV Service Re uest# <br /> MASTER WATER WELL PERMIT <br /> EHD 43-02-006 <br /> 5/7/2002 <br />