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(D [��MVEL Nsw, WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL:i H DEPARTMENT 304 E WEBER AvE 3-FL-STOCKTON CA 95202-(209)468-3420 <br /> n -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> MAY `9 p r <br /> JOBADDRESS ,36)3 jO S, 7—,exA� $� CITY/ZIP <br /> ENVIRONMENIQ!iT APN PARCEL SIZE <br /> PERMIT/SE %///���xrAME Po-I r C /`1.Q ,ew<S PHONE <br /> �/c� <br /> OWN'ERADDRESS /PCO Bok :Z25:2 <br /> CITY/STATE/ZIP <br /> CONTRACTOR sg�&y I �Jp�'SG,rS / e q <br /> CONTRACTOR ADDRESS 9J dPj!: NDM AI G/✓�E CITY/STATE/ZIP FGYN/ANA. C� 9eL <br /> SUBCONTRACTOR N/� <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CTI"Y/STATE/ZIP / <br /> LICENSE C-57 13 C-61 13 D-09 0 Other :NUMBER S1 EXPIRATION DA'Z'E W <br /> GEOGRAPHICAL INFORMATION: Coordinates X }' Township Range Section <br /> INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifd,Herem f Owner atv y>u•m arrc untan Name ur P one u <br /> TYPE OF WORK ❑New Well O Replacement Well ❑Well Altcration/Modificalion 0 Test Hole .Other, _ <br /> P<Monitorin6 Wells 12 namh—rweas u numarnfbodngs — nurwofborin <br /> y{Soil Boring(s) � l ❑Geotechnical Its <br /> 0 Well Destruction 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal <br /> ❑New Pump 0 Pump Replacement 0 Pump Repair 0 Cross-Connection Repair <br /> WELL CONS'IRUCTIONY <br /> Drilling Method 0 Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool 0 Push Point V OtherA/R 4yiA— nCP/bp r�L',TJ <br /> Proposed Well Depth /3V 0 Excavation_ �? _in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 410 0 Steel XPlastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth'vl,Q R 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite %solids) 0 Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted <br /> Grout Placement ethod Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: Width It Length B Thick in 0 Christy Boa gstove Pipe <br /> PUMP Submersible 0 Turbine 0 Other HP Pump Set^/30 tt Standing Water Level ya�ft <br /> WELL DESTRUCTION ❑Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br /> Well Diameter_in Total Depth It Depth to Water ft 0 Casing to be Perforated from ft to ft <br /> Sealing Material 0 Neat Cement(94 Ib bag/.f-10 gal watery 0 Sand Cement sack mix/7 gal water 0 Bentonite Pellets <br /> 0 Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File 0 Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall 0 Other <br /> 0 Complete with Mushroom Cap It below grade 0 Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKER ENSATION LAWS. <br /> 1 it 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 'may <br /> SIGNED TITLE ,6"'j o,e DATE .LOvy <br /> I ## <br /> DEPARTMENT USE ONLY <br /> Apphcauon Accepted By Date Area Employee IDP <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By_ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Amount Ch-k#/ Received Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Cash B Service Request# <br /> EHD 43-02-006 Master Water Well Permir.d« <br /> 6/20/2003 <br />