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SAN JOAQUIN COUNPYENVIRONAIENTAL HEALTI DEPARTMENT 304E WEBER AVE 3•o FL-STMKIDN CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT J� CALL(20 -7697 FOR INSPECTIONS EXPIRES I YEAR FROM ISSUED JOB ADDRESS fJ re, /♦{ CCTV/ZIY 1 YC 1 \Ve Il l f�n/'1 _I m ,. /I CROSS STREET CC lvl 1:- s Q,ln S1-rCef APN FIo I— S'DO(* °o rz PARCEL SIZE p OWNERNAME C✓d P"" /l1.1M PRONE N2CA)59"?-3337 OWNERADDRESS 13$ ParaIle I AvenlAe CITY/STATE/ZIP Rlipcn . .�A�j9'55" ns. r5I'10.1A1 EnVI/DnmtgT�al &-In�raSi'r'uf' I I, ^ca PIIONE (9 S}Ldp -2Z(o3 GBIRWPPEIRADDRE55 O r •CG CITY/STATEJZIP I(DnCnr' -,EA _/4 2 C"°� Dr' P.. Stln�iAl PRONE-(425)383-5810 gYBCONTMCTOR 1 /� e BNRCONTMCTOR ADDRESS SO !-I l�oQGI. CITY/STATE/ZIP Marin e-[-'(2A45551 oG G�� LICENSE C-57 IJ C-61 ❑D-09 ❑Other p nN..U.tMM�fBERq 8 1 5 EXPURRAAT^ION DATE— p GEOGMPHICAL INFORMATION: Coordinates xG382996.91 Y-7.091 I 1951& Township .ems Range_s. Section 21 INTENDED USE %Domestic/Private ❑Imgelmn/Agriculluml ❑Industrial O Water Quality Monitoring ❑Soil Sampling/Chancteriulion ❑Public Water System IfriRe,en,rmm Umermer YDem .me om¢r Name o,Phone Number TYPEOF WORK ❑New Well O Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) nombmofwelis ❑Soil Boring(s)_ numberortorn.p ❑Geotechnleal numhvofbodop .Well Destruction ❑Out-OBService Well ❑Out-Of-Service Well Renewal O New Pump ❑Pump Replacement O Pump Repair ❑Cross-Connection Repair WELLCONnHUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger E3 Cable Tool ❑Push Point ❑Other Proposed Well Depth R Excavation in diameter DOpen Bottom 13 Gravel Pack/Gravel Sim mdiameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Cuing Diameter_in Thicknes.WGauge/ASTM Sched ❑Sucl ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neel Cement(94 lh hug/5-I0gal carer) ❑Sand Cement .mckseir/7 gal wamr ❑Bentonite(20%Solids) ❑Manu lecturer Spec%Solids_% Name ❑Spoeson File OSpecs Submiued Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By O Driller ❑Pump Comracmr ❑Other ❑Concrete Pedestal Dimensions: Width_it Length_R Thick in ❑Christy Be. ❑Steve Pipe PUMP ubmersibie E3 Turbine ❑Other HP Pump Set �l 01 S ending Walerlsvel Il WELLDenRuCnON ❑Open Bottom ❑Gravel Pack E3 Uncured Other rl Well Diameter'Lin Total Depth 110 R Depth m Water Il ❑Casing to be Perforated Imam_It to_ti Srding Material KPIcat Cement(94 lb hug/J-10gu1 water) 11 Sand Cement suckmis/7 gal water ❑Bentonite Pellcut ❑Bentonire(206/a solids) ❑Manufacturer Spec%solids_% Name OSpecson Filc ❑Specs Submiued Placement Method V[Pumped ❑Free Fall ❑Other 13 Complete with Mushroom Cap R below grade '6[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. HN 44YHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED LyJ r 7 7 T(M_l TITLE //�A ATE A 138 It`� IoD� F in I(lell r12 ORIVEWAT � GAR I N I J/ DEPARTMENT USE ONLY Application Accepted By 1•\• Date -hillil Arae Employ.IDN 9y7- Grout Inspection By Date ), SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Dale .1( 7 Q y ComirucleJ\Veli Depth R COMMENTS d.r f6'{90n 0 C-.�S l PE SC Amount Check#/ Rea ved Date Perrnill Invoice# Wall IDN Codes Into Remitted Cash By Service Request 0 I B l `d lip 03- 0*7 7 EHD43-02-006 MASTER WAl'ER WELL PERMIT 5n12002