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WELL I PUMP PERMIT <br />SAN JOAQUIN COUNTY ENYIRONMENIAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL- STOCKTON CA 95202 - (209) 468-3420 <br />NUN -REFUNDABLE PE�RRM�Ir7T +y} �} A/f, ALI, (2119)/9/5/'31/-7497 FOR INSPECTIONS E[rIKEN II YEAR FROM DATE ISSUED <br />JOB ADDRESS �`^ r 7,✓1 �/} CITY/LIP ZeJ44 I 2 <br />CRQCS STREET' / ��' AP, -��✓' PPPAARCCELS17X <br />OWNER NAME �/U tt PHONE <br />OWNER ADDRESS! CITYISTATE/ZIP <br />CONTRACTOR <br />CONTRACTOR ADDR— 43&3 t I,�..n _P � r s� CITYISTATFIZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS _ _ CITY/STATaEIZIP <br />LICENSE 0C-57 0C•6i 0D-09 - Zthct4r_,0_,1O� NUMBER �.3r%7 ✓t� E.N.TIONDATE <br />GEOGRAPHICAL INFORIMATION: Coordinates X Y Township Range Section <br />INEENDEDUsEtunes:/Private ❑ Irrigalion/Agricultural ❑ Industrial ❑ Water Quality Monitoring O Soil Sampling/Chalactenzatfon <br />❑Public Water Syysstem <br />Ifdrfferent fm Owncc- a¢r. ysrem ante [ontan �emc a one um r`— <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteralion/Modihcation ❑'rest Hole ❑ Other <br />❑ Monitoring Well(S) —baofvells mamber of borings number of borings <br />g O ❑ Soil Boring(S) __ ❑ Geotechnical—,,, <br />❑ We 11 Destruction Q Ouz•Of-Service Well O out -01 -Service Well Renewal <br />rl —., o., n D-- o. rl r. erg tln n, <br />WFLL CONSTRUCTION <br />Drilling Method O Mud Rotary 13 Air Rotary O Auger Cl Cable Tool ❑ Push Pamt ❑ Other <br />Proposed Well Depth R Excavation._ in diameter CI Open Bottom ❑ Gravel Pack! Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter __in Thicknesc/(iauge/ASTN! Scher Q Steel ❑ Plastic Q Stainless Steel ❑ Other_., __ <br />Grout Sea] Depth ft ❑ Ncat Cement (94 lb hug / 5-10 gal water) 4O _. y <br />Sand Cement, uck mix 17 gal water <br />❑ Bentonite (20% solid.¢) ❑ Manufacturer Spm % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other — _ f __ 0 Retardant / Accelerator (name) —___ <br />PEDESTAL lnstallSd By ❑ Driller ❑ Pump Contractor ❑ Other <br />Concrete Pedestal Dimensions: Width 1: Length_ft 'thick in ❑ Christy Box ❑ Stove Pipe <br />r <br />PUMPINMubmersible ❑ Turbine ❑ Other HP 2 Pump Set _jCj-. R Standing Water Level ai It <br />WELL DESTRUCTION ❑ Open Bottom O Gravel Pack C Uncased Q Other <br />Well Diameter in l utal Depth tt Depth to Water --ft ❑ Casing to he Perforated from __ _ R to ti <br />Sealing Material ❑ Neat Cement (94 th hag /5-N/ gal water) ❑ Sand Cement suck prix / 7 gal water 13 Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % Name .,_ ❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free Fall Cl Other <br />O Complete with Mushroom Cap fi below grade ❑ 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 REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENS ION LAWS. <br />1: U I X1�t F NOTICE REQUIRED FO SPjiCTIONS — PLEASE CALL (249 953.766997 ^G� <br />SIGNED TITLE I`- -l__ DATE C25 <br />tom! <br />W <br />W <br />DEPARTMENT USE ONLY <br />Application, By Date -Cf- _n .3 Area i2_ � � _ _ Employee IPA NILv�Av <br />Grout Inspection By Date _ / ❑ SPECIAL Well PerMit / <br />Pump Inspection ByDate �Z(a3 ❑ WAIVERReceived <br />Destruction Inspection By- _ .4 Date _ Constructed Well Depth ft <br />COMMENTS <br />PE SC Received �LecJtillJ Amount Date PermlU Invoice k Well IDn <br />ode, <br />Info By Cash Remltted Service Request it <br />3�'�-t5 -7-', 1 132L--) I G7IC0 7!f1n---, L51000?eAll <br />EHD 43-02-006 MAS- ER WATER WELL PERMIT <br />!2/6/2002 <br />