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�(j[,`�jL�—I� �Jjl� WELL/PUMP PERMIT SAO JOAQUIN COUNTY ENvLRONMENTAL HEALTIt DEPARTMENT 30:E N\'EBLR i'.t'E Y°FL-STOCK-I'ON CA 95202-(209)468-3420 MAY R - EFUNDABLE,PERMIT QCA/�LL,(209)953-7697 FOR INSPECTIONS IONS EXPIRES i YEAR FROM DATE ISSUED JOB ADDRESS 30350 J c T/e4r L 7 &� y� CITYrLIP MONMENT bT I REETAPN PARCEL SIZE E. � PERMIT/5E � AME ,�"/t>C �.9ciF�C ^V .eia4.c Drtr,E,�/ 8 OWNER ADDRESSPo nBoX '/�r�s� CITY/5'rATE171P CONTRACTOR Y,� -N % �Y I4— 2)k At-//'VS .'' �J � CONI'RACTORADORESS 9y3�Ji 'f'S�NDA A�rE.VuE CITIMATVZIP Nmay, ��Z SUBCONTRACTOR N�/7 PHONE SuaroNTRAMOR ADORFSC / CITY/STATFl7.IP 9� LICENSE C-51 LJ C-61 ❑D-09 ❑Uthcr NUMlwit I _ EAI'IRA'I ION DAl E f pZ( GI!OGRA PI I ICA I.I NF1 IRNIA1 ION: Cuurdin Wes X V _ Tuwushlp Range Scctinn INl'ENUEU USE ❑Domestic/Private ❑Irrigalion/Agticultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactc,ualiou ❑Public Water System Ifdiff—Gom Owtcr. au - m —e Contact amc ur ..n<Nu -- TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ,Other,.___ _—�•_ umb—f—Els n ,-.r bunnas mtmbEr of borings I1�Monitoring Wet(s) Soil Boring(s) u,nt ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump R lacemem ❑Pump Repair O Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑At,Rotary u Auger ❑Cable'Fool Cl Push Point $UthcrA/.e s'' ,7 21 Proposed Well Depth /yD (1 Excavation J in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter?/ Conductor Casing Depth R Well Casing Diameter in Thickness/Gauge/ASTM Sched 410 ❑Steel xplastic ❑Stainless Steel ❑Other Grout Seal Depth'N ft R ❑Neat Cement(94 lb bug/5-10 ga!Is are,) ❑Sand Cement sack mit/7 gal water B-tonne °r:solids) ❑Manufacturer Spec%solids % Name ❑Spccs on File ❑Specs Submitted Grout Placementfethod Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By riller ❑Pump Contractor ❑Other ❑Concrete Pedntal Dimensions: Width_ft Length_R Thick in ❑Christy Box Store Pipe PUMP Submersible ❑Turbine ❑Other HP Pump Set~1.30 R Standing Water Levcl: / s fl WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth R Depth to Water ft ❑Casing to be Perforated from R to R Soling Material ❑Nee(Cement(94 lb bag 1 S-/0 go!acre,) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑hManufactsacr Spec%solids % Name ___ ❑Spccs on File '❑Specs Submitted Placement Method 0 Pumped I]Free Fall ❑Other ❑Complete with Niuslimom Cap R below grade ❑Complete to Existing Surface fad 1 HEREBY CERTIFY'THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKE<5i; NSA770N LAWS. RR 1 1 12d 1[OUR ADVANCE,NOTICE,'R?lI/fQU[RF;D FpUrR I�VjSPEC'i'fOVS 'M SIGNED TITLE�ry- i ✓ DATE ------------ DEPARTMENT USE ONLY Application Accepted By Date=S�rJ�r f�� Area Employee IDN - ! _ Grout Inspection By •+ ` /1 �Date �G.�' ❑ SPECIAL Well Pcnnit Pump Inspection Dy ,-f�II-ate ❑ N�'.11YER Received Destruction Inspection By_ Date Constructed Well Depth ft COMMENTS v PE SC Amount Check#/ Received )ate Permit/ Invoice N Well IDN Codes Info Remitted Cash BY Service Request# o I(X) oRk EHD 43-02-006 Nlasmr Water Well Pennit.doe 8/208003 ( `.O ori f� C