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/ SAN JOAQUIV COUNTY ENVIRONMHWELL PUMP PERMIT EN7AL FA~ ~'\VARThIENr - , - L--,-� 304E WEBER AVE 3a` cK-rpvCA95202-(209)468-3420 NON-REFUNDABLE PERMIT f }f (`fes ./`'[CALL 209 953-7647 FOR I $i�ECTIo s EXY j ,-YEAR FROM DATE ISSUED JOB ADDRESS 116-0 '�/J. !Q Je ejAle" Ct'IY1ZlP `� c CA !1I IT ' CRpsSSrREEr APN oLC „)Q' Cy r ip 1 r 3 A}RCE (/ L SIZE OWNER NAIr1 lEC. LIFrS�f[. . Pops � 'r`tCr� 75 OWNER ADDRESS CITYIS Zr�Z i � ,1 r 'N ) TATEIZI r'('(l� a CONTRACTOR _�-f ^y. GiZr;';C `T2c,tr,c1Lrl , n — PHONE �.?f �7) {{ zn�j�' I _. CONTRACTORADDRESS�p�� t CITYISTATEIZIP 1l-A11,64 SUBCONTRACTOR Gl:�x t1 i�'1�� /�r �/1 ypq - � � ROW,?-.. .1r��+� P110NE D L V SUBCONTRACrORADDREss qf.c? NOWT PC(. - CrTY15TArFJZtP t ^ Z LICENSE kc-57 ❑C-61 C7 D-09 ❑Other �,/! Nu%mnt ?~ S EXPIRATION DATE GEOGRAPinCALINFORMATION: Coordinates X • -�51- ^Ffr1GY"��g�'�j�] i's�Fl t[ Townsh€p Range Section INTENDED USE EI Domestic/Privaie Cd Irrigation/Agricultural ❑IndustrialWater �: Quality Monitoring BSoil Sampling/Characterization 11 Public Water System ' IfdifferenI from Ouner, atcr ysrcm ame- C^ntacr ame os Phan.Number TYPE OF WORK r$l'Ncw Well ❑RCD]ncement Well CI Well Alleration/Modification ❑Test Hole ❑Oiher - MMonitarin s -14 ^umbwaf-11. numhar oFborin g Well(s) _ I$SOil Borings) - ❑Geotechnical nurnberafb.d.gs ❑Well Destruction ❑Out-Of-Service Wel] C7 Out-Of-Service Well Renewal l ❑New Pum ❑Pum Re ]acement ❑Pum -R air Cl Cross-Connection Re air WELL CONSTAIiCTIO'J - - Drilling Method ❑Mud Rotary ❑Air Rotary Iffi Au erl f 0 Cable Tool ❑Push Point ❑Other {Ls Proposed Well Depth 2 5 ft EXCayalion .. E in diameter Q Open Bottom Isla Oravrl-flack/Grsvo4$ize 2(Z, in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth fl Well Casing Diameter It m ThicknesslGauge/ASTM Scbed_-4_ ❑Steel Arplastic 13 Stainless Steel CI Other Grout Seal Depth s fl -k Neat Ccmcot(94 ib bag/S-10 gal water) ❑Sand Cement sack mix 17 gal water 01Benlonitc(201%solids) Cl Manufacturer Spec%solids % Name 0Specs on File 0 Specs Submitted Grout Placement Method ❑Pumped j9 Free Fall ❑Other ❑'Retardant l Accelerator(name) PEDESTAL Installed By Z3fDriller 13 Pump Contractor ❑Other g Concrete Pedestal Dimensions: Width 1 =- fl Length ft Thick �' in4Chrlsty Boz ❑Stove Pipe PUMP O Submersible ❑Turbine ❑Other " HP Pump Set fl Standing Water Level !t WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Wel]Diameter_in Total Depth ft.i Depth to Water fl ❑Casing to be Perforated from It 4o R Seating Material ❑Neat Cement(94 ib bag/5-10 gal water) ❑Sand Cement sack:mix/7 gal water ❑Bentonite Pellets ' - 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted . Placement Method ❑Pumped ❑Free Fail O Other ❑Complete with Mushroom Cap fl below.grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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 I5 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION A IPHOUR ADVANCE NOTICE REQUIR D FOR INSPECTIONS O f ! SIGNED l{/L TITLE ''- Ila-2s are j ,� ', 1 A DEPARTMENT US7 ONL //� /tom♦ Application Accepted By Date 1b3 Area I { Y Employee[D# /%IV•l,MW•2 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ::Date ❑ WAIVERRe¢eived Destruction Inspection By - Date Constructed Welt Depth ft COMMENTS PE SC Amount Check#/ Received Permit/ Codes Info Remitted Cash B Date Sere Re pest# Invoice# Well ID# 3 EHD 43-02-006 Master Water Well Permit doe 2114!2003