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MI M 24 HOUR ADVANCE NOTIq REQUIRED FOR INSPECTIONS <br />TITLE SIGNED 1GYP4 -/ /211-/D DATE <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 °' FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br /> <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9 0. IA/ . A/C crry/zip cA c/LS-2_,W <br />69,0,JC11 <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br /> <br />PHONE <br />14,bl C_A 93-2,vo <br />PHONE ty10 371---04-77 <br />PARCEL SIZE <br />9) 30- lt70 <br />cA cts-cLo <br />PIIONE (CI tc,) 6 2 1-33-8-,s <br />sA-cicittiwAJNcii °cm CITY/STATE/ZIP <br />LICENSE b4-57 0 C-61 0 D-09 0 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X Township .3 Ar Range t,lg. Section I+ <br />CROSS STREET L. tAta CC14C-4 APN <br />OWNER NAME <br />OWNER ADDRESS c310 w TRAnick <br />CONTRACTOR iilc. <br />CONTRACTOR ADDRESS 3(4 00 1165 1 CS 0/1/ , 1- <br />SUBCONTRACTOR hirct-t-Ca_ AkiLLIA/cD <br />SUBCONTRACTOR ADDRESS S3 60 S • 1/174 Tr. /1"446.— <br />NUMBER (0726,17 EXPIRATION DATE <br /> 03 :SS31JCIGV 311S INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial ",Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole <br />number of wells number of borings 0 Monitoring Well(s) 0 Soil Boring(s) <br />,Well Destruction /IA 14d? ,2.. '3 0 Out-Of-Service Well <br />0 New Pump 0 PumpReplacement 0 PumpRepair <br />0 Other <br />number of borings 0 Geotechnical <br />0 Out-Of-Service Well Renewal <br />0 Cross-Connection Repair <br />WELL CONSTRUCTION <br /> <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool <br /> <br />Proposed Well Depth ft Excavation in diameter <br />0 Push Point 0 Other <br />0 Open Bottom 0 Gravel Pack <br />ft <br />/ Gravel Size <br />Steel 0 Other <br />in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless <br />0 Sand Cement Grout Seal Depth ft 0 Neat Cement '94/h bag / 5-10 gal water) sack mix 17 gal water <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />WELL DESTRUCTION 0 Open Bottom 0 Gray I Pack 0 Uncased <br />Well Diameter 2,,_ in Total Depth ft Depth to Water <br />0 Other <br />2._ ft 0 Casing to be Perforated from ft to ft <br />Sealing Material )(Neat Cement (94 lb bag/ 5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % <br />sack mfr 17 gal water 0 Bentonite Pellets <br />0 Specs on File 0 Specs Submitted Name <br />Placement Method S.Pumped 0 Free Fall 0 Other <br />*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 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 COMPENSATION LAWS. <br />qs Lt <br />Application Accepted By <br />Grout Inspection By <br /> <br />Pump Inspection By Date <br /> <br />Destruction Inspection By <br />COMMENTS 3 111 c1-tt St WS fiA.J.4,-1-01Le <br />DEPARTMENT US 0 LY <br />Date /7 17 Area Employee ID# <br />Date <br />Date <br />SPECIAL Well Permit <br />WAIVER Received <br />, Constructed Well Depth <br />chcrLA(t&t. <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Amount <br />Remitted <br />Check#/ <br />Cash <br />Received <br />By Date Permit/ Invoice # Well ID# r.L.4-5,4uaty....„ <br />a 56.2- 6()- e-o - /1(7if /-11<- (21,71 ckb012.16 9. tA3PC2bL-t.38/ <br />EHD 43-02-006 <br /> MASTER WATER WELL PERMIT <br />5/7/2002