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WELL/PUMP PERMIT <br /> S AN JOAGLAN COUNIY ENVIRONMENTAL HEAL 111 DE PAR I MINT tags EAST HA.ELroNAVENUr-SIOCKfONCA 95205 4232(209)466-3420 <br /> NON-REFUNDABLE PERMIT WWW.5i90v.or910hd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Sot rrench Camp Rd. CITYT2:IP Stmklnn/CAN5231 <br /> D <br /> CROSS STREET S Nrpod WRY APN 117-05-025 PARCEL SIZE 81)77 Ac LAND USE APPLICATION X <br /> OWNER NAME CHI/Arg.—I.ns CA.L P PHONE <br /> OWNER ADORE 55 527 W.71h Street.Sudo 200 CITYISTATE/ZIP Los Ang.lns,CA,9001A <br /> CONTRACTOR ENGEO Inmrporal PHONE 2D9-83',0610 <br /> CONTRACTOR AoDRE35 17278 Golden Vallny Parkway CITY/STATEop LAlhrop1CA195330 <br /> SUBCONTRACTOR/CONSULTANT West C...I Exploration PHONE 209-965-15A1 <br /> SUBCONTRACTORICONSULTANT ADDRESS P.O.Box 133 CITY/STATE/IJP EscalwVCA/95320 <br /> LICENSE EC-57 ❑C-61 0D-09 ❑Othef NUMBER 810761 EXPIRATION DATE 11110012 <br /> BILLING PARTY: ER aCONTRACTOR ❑SUBCONTRACTOR/CONSULTANT __ <br /> DoMEsnc WELL SAMPLING:. General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> Domestic/Private -Irrigation/Agricultural - Industrial Water Quality Monitoring Q Soil Sampling/Characterization <br /> Public Water System <br /> INTENDED USE <br /> If dltlorem hom Owner: Water System Name Contac)Nam.or Phon.Number <br /> TYPE OF WORK New Well Replacement Well IWell Alteration/Modification Other <br /> ❑Monitoring Wells) X of wells Soil Boring(s) a of bcdngs O Geotechnical 3 IF of Wrings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair :Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary - Air Rotary 2 Auger Cable Tool Push Point ❑ Other <br /> Proposed Well Depth 30 f1 Excavation A in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> -I Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched :1 Sled Plasfic Stainless Steel Other <br /> Grout Seal Depth 3�3 ft ❑� Neal Cement(94 Ib bag/5-70 gal water) Sand Cement sack mrxf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped QFree Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in 'Christy Box Stove Pipe <br /> PUMP Submersible'Turbine -Other HP Pump Set It Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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 COMPEN ATIO LAWS. <br /> MINIM 8 I� VA E NICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - - TITLE Staff Engineer DATE 7126121 <br /> EkFNT <br /> QED <br /> 7 202, <br /> �EN�q NTy <br /> ARTMENT <br /> 49 9 <br /> DEPARTMENT USE NLY <br /> J1 < <br /> Application Accepted By - C Dale 7 Area / tJ(. J"Employee IDX —� <br /> Grout Inspection By Dale 2A SPECIAL Well Permit <br /> Pump Inspection By Date -. WAIVER Received <br /> Soil BoringIns ction B Date Consitructed Well Depth ft <br /> y S <br /> COMMENTIS E�YY1 YK1(' ti L"•E' �`•.� f G <br /> l+ 'P is �7Fy-oc✓ lir 3� I 1. �� QSt Ctlfik PAQ <br /> PE SC Received Check#/ Amount Date PerrniU Invoice X Well IDX <br /> Codes Into ANL Cas Remitted I es <br /> 431d 7 <br /> EHO 41U8 ./1lwo WELL/PUMP PERMIT <br /> 12gd3v��.3 <br />