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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL Hill DEPARTMENT 304 E WESER AvE 3 OC <br /> NON-REFUNDABLE PERMIT 1- -7-2-aALL(209)953-7697 FOR INSPECTIONS EXPI*1 YEAR CA 95202-(209)468-3420 <br /> 1FROM DATE ISSUED <br /> Jos ADDRESS 63- Crry/Zip LvSt <br /> CROSS STREET APN D(2 �S I-Z 0 Oq PARCELS. q-7 <br /> OWNERNAME PHONE .7 Ij <br /> OWNER ADDRESS A-zUt., AO(-. CITy/STATE/W.S4-(,"^ (2-k -K2=21 <br /> CONTRACTOR kJL, o,✓® At ASSOC-', JAL. <br /> PHONE S,;�® 1';�&-)-,L-0 <br /> CONTRACTOR ADDRESS �72,,"+^ Ajc.- C1111STATEMI-00J I�1 Ut' 'I",)& Z- <br /> SUBCONTRACTOR S 0.1p e W PHONE <br /> SUBCONTRACTOR ADDRESS PIW44'C�U/ Si-. C./STATEM1 Do/<- ek 9 12-1-+ <br /> I LICENSE J(C-57 13 C-61 E3 D-09 00the,---- NUMBER77,4448 EXPIRATION DATE <br /> GEoGRAPHicALINFoRmAmoN: Coordinates X Y > ,C '%1' 1 cptJ Township_ Range_ Section <br /> INTENDED USE gDomestic/Ptivate 13 Irrigation/Agricultural E3 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Chamcterization <br /> 0 Public Water System <br /> If different from Owner. Water System one Coated Name or one Number <br /> TYPE OF WORK *New Well 0 Replacement Well 0 Well Alteration/Modification 13 Test Hole El Other <br /> '5(Monitoring Well(s) nurnber.f-11, 0 Soil Boring(s) nureb—fbminp 0 Geotechnical -.W of bores, <br /> 0 Well Destruction 13 Out-Of-Service Well 0 Out-Of-Service Well Renewal <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary KAuger 0 Cable Toot C3 Push Point 0 Other <br /> Proposed Well Depth (20 R Excavation 9®0 in diameter 13 Open Bottom (,.Gravel Pack/Gravel Size I-31Wi.diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter I in Thickness/Gauge/ASTM Sched '40 13 Steel 9a!lastic 0 Stainless Steel 0 Other <br /> Grout Sea] Depth 'S ft drNeat carnant(941b bag/5-10 gal ware,-) 13 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(201/o solids) 13 Manufacturer Spec%solids_% Name 0 Specs on File 0 Specs Submitted <br /> Grout Placement Method kPamped 13 Free Fall 0 Other 13 Retardant/Accelerator(name) <br /> PEDESTAL Installed By :Drill. 0 Pump Contractor 0 Other <br /> 13 Concrete Pedestal Dimensions: Width_ft Length_ft Thick in 0 Christy Box 0 Steve Pipe <br /> PUMP 0 Submersible 0 Turbine 0 Other HP_ Pump Set R Standing Water Level ft <br /> WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br /> Well Diameter in Total Depth ft Depth to Water ft 0 Casing to be Perforated from_ft to ft <br /> Sealing Material 13 Neat Cement(941b bagl 5-10 gal water) 0 Sand Cement sack mix/7 gal water 13 Bentonite Pellets <br /> 0 Bentonite(20%solids) 13 Manufacturer Spec%solids_% Name 0 Specs on File 13 Specs Submitted <br /> Placement Method 0 Pumped 0 Free Fall 0 Other <br /> 13 Complete with Mushroom Cap_ft below grade 0 Complete to Existing Surface 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 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP%rSATI0AAWS. <br /> NOTICrQUIRED F PECTIONS <br /> r <br /> ,OfeC,,ORX <br /> SIGNED TITLE DATE <br /> 717-= <br /> DEPARTMENT U�7EO;ly <br /> Application Accepted Byg--L 17 Area Employee ID4 041 <br /> Grout Inspection By Date E3 SPECIAL Well Permit 0\ <br /> Pump Inspection By Date 13 WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth_It <br /> COMMENTS �PMAENT <br /> AC® <br /> PE SC Amount Check#/ Received Date P Invoice# Well ID# <br /> Codes info Remitted as By Se.,.=,.,.t# <br /> A&C LM ZW' E44-13 -Art &hiLel- 5ef:026z-d JUN 1 9 2003 <br /> AN JOAQUIN COUNTY <br /> UBL.IC HEALTH SERVICES <br /> 2114n003 <br /> ) <br /> EHD 43-02-006 Mager Water Well Pe "RONMENTAL HEALTH DIVISION <br />