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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNT\'ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCK'TON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-769 " BCTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> _ rr <br /> JOB ADDNES.S <br /> rr�f i,�6Ror�clbND CI„',zD. Lc<ice,(�,cid 9523'7 <br /> CROSS STREET 1/2-hitt I C A+ x+" c f FI Iv X/ ( L (,.'7 ��(7(�—`IV PAItCF.LSI%E Ar.a)sm r I5tic <br /> n I / r <br /> OWNER NAME RG 1))je-1 T— (4f)MVV�r—r �J + /L—PHONE( O1i) &C,I --'I 37`'j <br /> OWNERADDRESS I7-1 L' (J rLf(',g f� -I A )er/l C CITY/STATE/LIP fC_--e-4.-A,C/a q y Z 3 7 <br /> �t I- E t� <br /> CONTRACTOR /'l LN41 7 lPIIONE CC��IL) q Z_+ -LY'_1- -- <br /> CONTRACTOR A DDRESti Tf'� !-I Ic�.iC(-'. 1-n:nr)- fZC1 5'tL �'�7 CITY/STATE/ZIP Ji�L1=r-'t 1`'v e.v�G\ -A c7S LC 7_(C' •�( <br /> SUBCONTRACTOR 25P L;C- r A{Vl -fL�I(�e•-11 hirf:l/SJ�C_ • PRO.*4F.7-C-e'1r ) �,.•I(eg5-�7-7 <br /> SUBCONTRACTOR ADDRESS 2 IES L✓1 n W A I'V't DC. CIT-'/STATE/ZIP <br /> LICENSE 2C:-57 ❑C-61 ❑D-09 ❑Other NUMBER CS7-5'!22 0 au'. EXPIRATION DATE 3C I�, <br /> 3 \ <br /> / c. 7. > WIL-1- <br /> GEOGRAPR[CAL INFORMATION: Coordinates X Y Township Range Section C <br /> INTENOEO IISE Domestic/Private O lrngatiorl'Agncuft I O Industrial Vater Quality Monitoring ail Sa mpling/Chzmcleriiation <br /> ❑Puhhe Water Syystem <br /> 11duivmnu mem(1..mer- W-, l..... -. -Tam Sou,:........ <br /> TYPE OP WORK l-/ <br /> P eew WcR O Replacement Well O Well Alteration/Madilication 0 Test Ilole 0 Other <br /> p1'Monnoring Well(s) r—D orevnl 0 Soil Boring(s) nunlberorborings 0 Geotechnical numbmorboriop <br /> 0 Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> 0 New Pump ❑Pump Replacement 0 Pump Repair 0 Cross-Connection Repair <br /> WELL CONST'RUCT'ION St-.-C )a7ACHC'0 <br /> Drilling Method 0 Mud Rotary 0 Air Rolary ID--ger 0 Cable Tool 0 Push Paint-- ❑Other_ <br /> Prof -I%VvlI Depth__I(i_�� It f sravanou0__ in diameter ❑Open Buuam Or l//a"I[lack/0-el Sire I L in diameter <br /> 0 Cunductaf Casing ul diameter / Conductor Casing Depth It Iwtt <br /> Well Casing Diameter 7.5 in Thickness/Gauge:ASTM Sched 71C PLIL 0 Steel [d'Iflastie ❑Stainless Steel ❑Other <br /> Grout Seal Depth 0 -5 S 11 "eat Cement(94/h/erg/J-10ged Nater) ❑Sand Cement .rarR mit/7 gal water '-4, <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 0 Specs on File 0 Splcs Submitted <br /> Grout Placement Method EJ l umped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed IW ruler 0 Pump Contractor ❑Other �/ <br /> 0 Concrete Pedestal Dimensions: Width_A Length It Thick in 0 Christy Bo. ud atavc Pipe <br /> PUSIP 0 Submersible 0 Turbine ❑Other HP Pump Set It Standing Water Level ft <br /> WELL DESTRUCTION 0 Open Bottum 0 Gravel Pack 0 Uncased 0 Other <br /> Well Diameter in Total Depth R Depth to Water h 0 Casing to be Perforated front R to 11 <br /> Sealing Material ❑Neat Cement(94/h bag/3•10gal Crater) ❑Sand Cement sack ao../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 0 Other <br /> 0 Complete with Mushroom Cap It below grade ❑Complete to Eytsting Surlttce Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAW'S,AND RALES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS r <br /> CURRENT AND ACTIVE WITH THE CALWORMA CONTRACTORS STATE LICENSE BOARD AND THAT I ANI IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOER ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED l �llf._h/r.,�.a-,"'� Ttrl.I. SL�ItGrwe r1 owne. D,ert: /Z C) <br /> QC✓- <br /> _ -- Yl aOpFar1 <br /> _ __ <br /> CA 9 n; <br /> 1» <br /> N <br /> 1.177- <br /> 1-1 T <br /> .177 Ar1 e AD <br /> >tl[,, Ae7 y�[Y�e /,(f t71�yc� 'K��Yr•) u l y sI - el <br /> sv.cev ono <br /> PAtow <br /> �-�Tlfi t t fa Rro l dV.luc IINw <br /> `�F jyDf- <br /> e ��xy.j��•il" t �a P<"Moov,tne <br /> J * � k'e t avN /` 'm•' vawe lr®6r <br /> 17- �.�IF�, t� ca[tti sore alms <br /> Rahe h et r4 J[r r%i/ Bartel Anes 6.41 <br /> Sys t; T� [Wap Arta l716 <br /> -W,SA <br /> fr <br /> T'.G...a utas <br /> m�nmc a of - <br /> y t q"y� ,ti 1S st a of <br /> 11-•VVl3ahLL. !���.t}' +�V 9atM WAole t _ <br /> { <br /> Application Accepted By Date O Area Employee IDH <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 An10Unt Chec"/ Received Permit/ <br /> Codes Info mitted Cash By Date Service Re uestH InvoiceH WeII1DH <br /> 0 <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 5/72002 <br />