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- FILE <br /> WELL/PUMP PERMIT COPY <br /> SAN JOAQUIN Cou%-n-ENYIRONAIENTAL HEALTII DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-769 ECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ rn <br /> e tt��t..:A 2aA- aT,'1ztP Jr-,,:14e c C. '?57-3'7 m <br /> JOn ADDRESS I 1 f r��( <br /> r v <br /> CROSSSTREET Z rtitr'c= /N!t'r'I-I- Cf f•I(J�� 12- L.'.�l•-ISC—�� /PARCEL SIZE AXf 6FCIC.15,1 e F <br /> OWNER NAME i:C•he✓T- 141)" rrG ff /PHONE (�'-U�r) ft'O1 -C?37q <br /> OWNERADDRESS 17 1 t'S � rpt►��.(�+��/ Rr'A CITYIS'I'ATEI-LIP L£C_k e-4:.-A�C/��Iq r> Z 3.7 ` <br /> CONTRACTOR I I- 9 7-+ - +q <br /> CON'rR,1CFOR ADDRESS -� L 1 I C'�� r T,,;/j �I�L� , S1L'�i!' CITI'ISTATFJ-LIP 5,it- 'r'�I'','t�v-CG/,�f A C?S�rJC 2�2' <br /> SUBCONTRACTOR S PL`�-'tt'LA flit--L%/�t•-/;YI 1'nJ/SJ�1(-- /PIIONF.'/� <br /> SUDCONTRACfOR ADDRESS 2 3(eS L✓I n BAJA I's'1 Df-, C.'11'/STATE/ZIP <br /> LICENSE STC-5" 0C-61 0D-09 ❑Other NUMBERES PIRAT]0NDATE <br /> 3 [ 7. •> t I <br /> CEOGRAPHICALINFORNIATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrialuter Quality Monitoring oil Sampling/Characterization <br /> ❑Public Water syYstem <br /> �:Li.lunu(nun —,.)'a1,I, .,nm �nIIL,CI 'I anLL unl.r <br /> TYPE OP WORK �Q_�'ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test ilole ❑Other <br /> 6XSlonitoringWell(s)_L "0"'btrDrwrn. ❑Soil Boring(s) numbarofborings 11 Geotechnical wmb<rorbodngs <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> - ❑New Pump ❑Pump Replacement ❑Pum Repair 13 Cross-Connection Repair <br /> WELL CONSTRL'C1'ION $i C /4TAC10 1"tlnw4ln <br /> Drilling Method ❑Mud Rotary ❑Air Rotary M-Alrg�r ❑Cable Tool ❑Push Point��LL❑Other <br /> Proposed Well Depth_f C_Q_.__11 l'\l'avlllittll__V__ _..,in diamhom eter ❑Open AlstlTl,rrvcl Pack/(;ravel Site rL in<liantcler <br /> ❑ConductorC'using in diameter / Conductor Casing Depth It ,tov, :riPii7 <br /> Well Casing Diameter 7_7 in Thickness/Gauge/ASTM Sched IQ PVC- ❑Steel Q'rrlustic ❑Swinicss Steel ❑Other <br /> Grout Seal Depth 0-S S it "eat Cement(94 th hag/5-10gal morel) ❑Sand Cement smk oris l7 gal water \ <br /> ❑Bentonite(2(r/,solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method efumped ❑Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed Rv P6riller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_11 Length 11 Thick in ❑Christy Box Move Pipe <br /> PUMP ❑Submersible ❑Turbine .❑Other HP Pump Set It Standing Water Level tt <br /> WELL DESTRUCTION ❑Open Bottom O Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth A Depth to Water ft ❑Casing to be Perforated from It to R <br /> Sealing Material ❑Neat Cement(9411,hug/5-10gal wafer) ❑Sand Cement .rack oris/7 gal water ❑Bentonite Pellets <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Frec Fall ❑Other <br /> ❑Complete will,Mushroom Cap__11 below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THC WORK WILL 13E DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COL'NTN ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS r <br /> CURRENT AND :xCTIVE 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 FOR INSPF:CTIONS <br /> SIGNED �,� 7�1t �/f ��� TITLES1��rGr Ele jcltIS^I-_ DATE. <br /> _--'_- <br /> N � - —- - Aaetart <br /> 4 e;ly; -1 A­Adds"a t otvoao, <br /> � 'M1`''I SAu.number D965 <br /> 2 � T. f' Sd a r[ct TFttaEW.1v <br /> 'l?WJt tx<��,r �'N r�� ;) I t� .:a. s I— Fa)T{Yp-I <br /> May L w t -10y <br /> r ca. uao. <br /> �¢ rjY €€�..Ilti�' ii44rrtr G, 1 M Wni l dY I 11]9'M <br /> u M., <br /> Baser <br /> -raja". D_ <br /> r x � - .t87 S r'�riA'iyyVT9�T9'Y' iiilt '�v� n vol e <br /> J - tr} r y * Imp •a Y 119%1 <br /> ae•s', 1.c 1 �� is Jf/':,=• vena sortt rams <br /> \wA St'!i lAx Fi w(7yj L� �1'� l' IMFq a 1116 <br /> T— <br /> R- <br /> Sqft <br /> SVR RW <br /> LY I� 1 y r. a c,& o1 leve <br /> r s s i t <br /> `Eiii <br /> y earn.whole _ <br /> ( •>r : r �"" muwHaa <br /> -Pla <br /> zi am <br /> >7 i <br /> Application Accepted By Date O Area Employee ID#iz / <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Cl WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth rt <br /> COMMENTS <br /> PE SC Amount Check#/ Received DatePermit/ Invoice WDIIID# <br /> Codes Info Remitted Cash 1lv pp Service Re steer# <br /> r 0 2Q' oo <br /> EHD 43-02-006 MASTER WAl"ER WELL PERMIT <br /> 5n2002 <br />