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DEPARTMENT USE ONLY <br />Date -1 Area 94 Employe: IN <br />o SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />61-) <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection B <br />Destruction inspection Fly <br />COMMENTS /19 /7V-6-feaeZLY./11e=?J ,P-,1341`17;2<; <br />Date <br />Dale //— <br />Date <br />/2 34r <br />SIGN <br />MINIMUM 24 HOUR VANCE NOTICE REQUIRED FO I 'PECT <br /> TITLE <br /> <br />, <br />to- TN; <br />EL <br />fio <br />t <br />-4 <br />- PLEASE C L (209) 953-7697 <br />ATE <br />tiru <br />WELL I PUMP PERMIT <br />s AN JOAQUIN COL NTY ENVIRONMENTAL HEALER DEPARTMENT 304 E WEBER AVE r" FL - STOCKTON CA 95202 - (209) 4611-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FDR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB:ADDRESS I I 61 SS- S. _ k..i.zyll (5--e-x... (2-19---- CITNIEIP 11164e-r-Oi q6-31(/ /- <br />e e/Mom C, L. CAc...„.., 0, Apr. .,9w-f C,"" 00 -7 PARCEL SIZE <br />OWNER NAME Aar \A AtArle L l'one6 445V- (c.cc,8.4.- C‘4cit-{2,-. PHONE 'a9) "j1.-2-2.S1 <br />OWNER ADORES:. / I 6 5 5 S - 1/1-/Y1 161 Tr)2A- oryisTAToLip yi„, ‘41"cejac ,6 --3W11 ,5N''' <br />CONTRACTOR )‘3 1... 1.1—"J&I,--11.-GNN. i"=" isC._, PHONE (.174() `nCi- —IN'4f g-s <br />CONTRACTOR ADDRESS 2 % 5 La. ekok r.A. '17Z:ot- CrrviSTA rLai r "Cci-l-F-,--1, 9 C A, 61/4 S. leG <br />SUBCONTRACTOR <br /> <br />PRONE <br /> <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-5'7 0 C-6I 0 D-09 C Other C--1 NUMBER 6,Z-7 Z EXPIRA EICIN DATE o175- <br />CROSS STREET <br />CITY/STATE/ZIP <br />GEOGRAPHIC AL INFORMATION: Coordinates X V Township Range Section <br />INTENDED USE t!FOomeSUCIPTiVate 0 I rrigation/Agricultura I C Indusn-ial 0 Water Quality Monitoring C Soil SamplingiCharacteHtation <br /> <br />0 Public Water System <br /> <br />If differcor, from Owner: Rano System Name <br /> <br />Contact Name n. P <br /> <br />TYPE Or WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole 0 Other <br />0 Monitoring Well(s) 0 Soil Dori ng{s) "ur"b`r nt Civocehtiical number of wells <br />0 Well Destruction C Out-Of-Service Well O Out-Of-Service Well Renewal <br />Cress-Connection Rcparr 0 New Pump lPurtirt Replacement 0 Pump Repair <br />number of bonnib <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool <br />Proposed Well Depth ft Excavation in diameter <br />0 Push Point 0 Other <br />0 Open Bottom 0 Gravel Pack / Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth lt <br />Well Casing Diameter in Thickness/GaugetASTM Schad 0 Steel 0 FIntic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (9416 bag/ 5-10gal wafer) O Sand Cement sack mix / 7 gal water <br />0 Bentonite (20% solids) 0 Manufacturer Styx % solids _ .__ % <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br />Name 0 Specs on File 0 Specs Submitted <br />Cl Retardant / Accelerator (name) <br />PEDESTAL Jots oiled By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width tt Length 11 Thick in 0 Christy Bon 0 Stove Pipe <br />PUMP ,11111Submersible 0 Turbine IO Other HP .1 1/-e_ Pump Set 1b- Ft Standing Water Level '31 tt <br />WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack Li Uneased <br />Well Diameter in Total Depth ft Depth to Water <br />0 Other <br />11 0 Casing to he Perforated from ft to 11 <br /> <br />Sealing Material 0 Neat Cement (94 lb hug/ 540 gal wafer) 0 Sand Cement <br /> <br />0 Ben lOrli te (200/s solids) 0 Manufacturer Spec %solids % <br /> <br />Placement Method 0 Pumped O Fret Fall 0 Other <br />sack ma I 7 gal water 0 Bentonite Pellets <br />Name CI Specs on File 0 Specs Submitted <br />0 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 REGULATSONS. 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 COMPENSATION LAW'S. <br />PE <br />Codes <br />SC <br />Into By <br />Receive°ILI25,1c#4, <br />Cash <br />Amount <br />Remitted Date —Permit/ <br />Service Request # Invoice ti <br />, <br />Well I Mr <br />"i34 05-0 id2 grqc_37 3-0 7Aior 3k00 g ',2 (4, So <br />OHS) 43-02-006 <br />12/6/2002 <br />MASTER WATER WELL PERMIT <br /> <br />rti