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WELL/PUMP PERMIT <br /> `SNAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 F.WF.BI.R AVE 3P°FL-STOCKTON CA 95202 - (209)468-3420 <br /> j NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE,ISSUED <br /> 1 r� y f V -��/' V <br /> JOB AUDRFSS L �I l-� 1 � CtTt'�LIP�lrC-IC_j-�T) Cn t'46A-D�_ � <br /> CROSS STREET APN 0+7,`-d Waw PARCEL SIZE' /d3 � <br /> 1-4 <br /> OWNER NAMC ii, it V l PHONE 1 � - <br /> OWNERADDRFS?` <br /> CONTRACTOR _ PHHO{t,NE.y�����YN- <br /> CONTRACTORADDRF, CITVISTATE/ZIP <br /> SUBCONFRACMI? 4 PHONE Al <br /> \\t <br /> �/ � V} <br /> SUBCONTRACTOR ADDRESS /4R�}Y/STATE/ZAP1� <br /> LICENse C-57 ❑C-61 ❑U-09 ❑Other NDMBEI�y,Liu v EXPIRATION DATE <br /> GEOf.RAPHICAL INFORMATION: Criardinttes X Y Township Range Sectio■ <br /> INTENDED(ISE )omesticlPrivale O Irrigation/Agricultural 1)Industrial ❑Water Quahty Monitoring CI Soil Sampling`Characterim6tin <br /> Public Water Svstem <br /> if Gir(crcn+let hwrwr - ixr'ysiemFnme -- Cin orTh�e RumSer <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altetation.'ModiScation ❑Test Hole ❑Other _ <br /> numhv of rel;s number of boring number of businas <br /> 13 Monitoring Well(s) _ 13 Soil Boring(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pum Pun+ Replaccinctic ❑Pum R tr ❑Crossl:onw lion Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Po;r.l ❑Other <br /> Proposed Well Depth—,_tt Excavatior;_ in diameter ❑Open Bottom ❑Gravel Pack 16ravcl Sizein diameter <br /> ❑Conductor Casing_ in diem^.ter r Conductor Casing Depth _ _it <br /> Well Casing Diameter In Thickntss+Gaug&ASTM SChed ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Groin Scal Depth ft Q Neat Cement(?IIA bag,15-10gal wr leer) ❑Sand Cement .rack mix i 7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids _% Name _ ❑Specs on File ❑Specs Submitted <br /> Grout Placement.Method ❑Pumped ❑Free Fall ❑Other ❑Rev rdanl/Accelerator(namel <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑ oncrete Pedestal Dimensions: Width it Length_ft Thick in ❑Christy Box O Stove Pipe <br /> PUMP i Submersible ❑Turbine ❑Othcr _ HP�W PumpSet,�4 Standing Water Level _ 0 <br /> WF.1.1.DEBTRUCrION ❑Open Bottom ❑Gravel Peck ❑Uncased ❑Other <br /> Well Diameter_in Total Depth_- _11 Depth to Water _ _R ❑Casing W be Perforated from tit to ft <br /> Sealing Material ❑Neat Cement(94 lb hag/5-10 gal»weer) ❑Sand C erlent sack mLr r 7,gal water ❑Bentonite Pellets <br /> ❑Bentonite(2010 solids) ❑Manufacturer Spec%solids__% Name _ ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap _ n below grade. ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE. WITH SAN <br /> JOAQUIN 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 AVD THAI' I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1 IMU11 2THU DV AN E NOTICE REQUIRED F INSP TIONS—PLEASE CALL(?09)953-7697 <br /> LQx�cJ/) <br /> .SIGNED TITLE 1 DATE <br /> nfP <br /> _ O U <br /> EI <br /> DEPARTMENT(ISE ONLY J / <br /> _ ;J Arca pa <br /> Application Accepted By _ Date �1/ Employee IDI; <br /> (;rout Inspectian By Date 1:1 SPECIAL Well Permit <br /> Pump Insp"tion I DateZ'/''v/ ❑ WAIVER Received <br /> Deslmction In•,pection By_ _ _ Date_ _ Constructed Well Depth_- a It <br /> COMMENTS <br /> PE SC Received theck#V Amount PerndU <br /> Codes Info B .as Remitted Date Service R uest p "voice# Well IDs' <br /> l;ziE °`' I I I 63 SRo03 6 33 51-7 <br /> it <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 12/012002 <br />