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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARI'MEN'F 304E WEBER AVE 3"FL-STOCKl'ON CA 95202 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 1 H <br /> JORADDRE.S 31,361 CITY/ZIP 444CX " <br /> - Y <br /> 1 A.,.� v <br /> CROSS STREET y� , /sl/l i�l e'40,A-� �/7� � / APN t25-5--310-Ig PARCELSIZE 11 43 <br /> OWNER NAME �LJt(, L'Sil,! Affz.Lr �N�jEJc�J - _ PHONE i L; <br /> OWNER ADDRESS J ( /"#-R;joe _ V CITYISTATFJZIP C+�T3 ga _�_ <br /> CONTRACTOR Wr . ! / J/IiL-' —_ agA T PHONE - g/ <br /> CONTRACTOR ADDRFSS.�J' Ie" _, �16 P/?&x l CITY/STATEJZIP 1[.tet <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRES i1 CITY/STATE/ZIP <br /> LICENSE <br /> LI ❑C'-61 11D-09 gp[her �[, J a NUMBER EXPIRATION DATE <br /> GEOGRAPHICALINPORMATION: Coordinates X Y Township Ranee Section <br /> INTENDED USE fk12mesticrPrivate ❑Irrigation/Agricultural O Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterintion <br /> ❑Public Water System Cn <br /> Ir different f m DD er aar Sy,w.N­ C..wt .—or r ae an <, V <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altemtion/Modification O Test Hole ❑Oi her �]I <br /> ❑Monitoring Well(s) 1p1Tb"aiwcn. ❑Soil Boring(s) numbcrorburinyy ❑Geotoehnical ^omberortwrinp I�, <br /> ❑Well Destruciian�y la Out-Or-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pum l0um Replacement ❑Pump Repair ❑Cross-Conncc:ion Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size _in diameter <br /> Cl Conductor Casing in diameer / Conductor Casing Depth I) <br /> Well Casing Diatmics in ThicknessfGaugeJASTM Schell ❑Steei O Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth it ❑Neat Cernent(94 th hug/540 gal water) ❑°.and Cement .rac'k mit/7 gal water <br /> I7 Bentonite(20%solids) Cl Manufacturer Spec%solids o/ Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor O Other <br /> ❑Concrete Pedestal Dimensions: Width_ it Length R Thick in O Christy Boa ❑Stove PI e <br /> PUMP 13 Submersible O Turbine ygjthcr��_ HP Pump Sete it Standing Water Level tl <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other T <br /> Well Diameter in Total Depth ft Dapth to Water R ❑Casing to be Perforated from tt to ft <br /> Sealing Material ❑Neat Cement(941h hag/5-10ga1»stet) ❑Sand Cement .ruck nri:/7 gal water ❑Bentonite Pellets <br /> ❑BenlOalte(209/6 solids) ❑Manufacturer Spec%solids __% Name ❑Specs on File ❑Specs Submitted I <br /> Placement Method ❑Pumped ❑Free Fall ❑Other__ y <br /> ❑Complete with Mushroom Cap_-___It below grade ❑Complete to Fitisting Surface Pad Ik <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 34OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> WORKERS COMPENSATION LAWS. <br /> VIMUM 24 HOUR ADVANCE NOTIC RE,Q TIRED FOR INSPECTIONS // <br /> SIGNED TITLE DATE /(! <br /> r <br /> • <br /> l <br /> IT <br /> V , <br /> r1 f 01-Ps <br /> DEPARTMENT USE O L <br /> Application Accepted B, Date Area oC 1 mployee ID# <br /> Grout Inspection By Date ❑ SPECIAL I Permit <br /> Pump inspection 2i-C_ lt' Date /<111116 � ❑ WAIVER Received <br /> Destruction Inspcetion By Date Constructed Well Depth rI <br /> COMMENTS <br /> PE I SC Amount QCLReceived Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted - By Service Request# <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> $/7/2002 <br />