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SAN JOAQUIN CouNTY ENVIRONMENTAL,HEALTa DEPARTMENT +Y 304 E WEBER AVE Sep FL-STOCKTON CA 95202 - (209)468-3420 <br /> IVON-REFUNDABLE Pirnr T CALL,(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> /5'r5t /` 'IArVTrfE Z <br /> JOBADDRE55 _, CITYIZIP ��� �72• I¢ 7 � <br /> CROSS STREET <br /> l _ PARE SIZEZZ <br /> p <br /> OWNER M 12 NAE •C • r- /y� r 'igNE <br /> OWNER ADDRESS L_A W.440 !1 CITYISTATFJLIP ! / 7AQ/ <br /> CONTRACTOR FI/v ro <br /> Ag <br /> r�rn €; ►v <br /> CONTRACTOR ADDREtS'S /. ' /-�y� �►l I J CI 1STgTFJZIP QI��J�"V f`^-7^C C¢�Q � `k <br /> SUBCONTRACTOR it _ 7 -7 lt� � `• <br /> SUBCONTRACTOR ADDRESS M J' /7 ' —' CITYISTATFIZIP <br /> LtCENSE C-57 ❑C•61 ❑D-09 ❑Other NumiWit EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates ?i; i1C rQ'Jt/r> ' v Township Rangr. Seeiion <br /> INTENDED USE -ZIR3)omeslic1Privale-� ❑lrttrigationlAgricultural ❑industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterizalion <br /> p Public Water Systet5 yL V11 <br /> trdifrertru franc Owner V E ysrem anx onrea anK or one um r � <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AiterationlModification ❑Test Bole ❑Other `1 <br /> XMoniloring Well(s),w umkcrarwas ❑SOLI Boring(s) numberofborinp ❑G�technical numbcrofborings �1 <br /> ❑.We11 Destruction n-W-j -/In(A-Of-Service Well 0 Out-OFService Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Poini ❑Other PIP <br /> Proposed Well Depth R Excavation to diameter ❑Open Bollom YlGrdvel Pack/Gravel Size-� in diameter r <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth _'tt <br /> Well Casing Diameter Z—in Thickness/GaugelASTM Sched !!fi2 -- ❑Steel XPlastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth j!�7--I� it Meat Cement(941h hag/5-10 gal wafer) ❑Sand Cement ,tack tnix 17 gal water <br /> 3--+5 ` AdBentonite(20%solids) ❑Manufacturer Spec%solids % Name E]Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped Kree Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ,Driller . ❑Pump Contractor 0 Other <br /> 1)gConerete Pedestal Dimensions:. Width 11 Length 11 Thick in D Christy Box Slove Pipe <br /> PUMP O Submersible ❑Turbine ❑Other HP__ Pump Set ft Standing Water Level p <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth 11 Depth to Water fl ❑Casing Lo be Perforated from It 10 R <br /> Scaling Material ❑Neal Cement(94 lb hag/5-10gat wafer) ❑Sand Cement suck tn&17 gal water ❑Benionite Pellets <br /> ❑Bentonite(200%solids) 0 Manufacturer Spec%solids_—% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other — <br /> ❑Complete with Mushroom Cap 11 below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATIOI+I 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> FNGKD t►X. <br /> SIGNED ITLE DATE li✓ �Lyy+c�C/� <br /> z <br /> a ..Iliiff <br /> ( fM u <br /> � ! I{atdtml LL <br /> W 1 <br /> Uj <br /> -1 <br /> _ o <br /> k:YAlt'1 Mlfav 111,. IVLY `r7 q <br /> Application Accept Date d/-/sue Area �`` / Frnployee I DtF <br /> Grout Inspcc 'on B, DalrG7�C�' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction inspection By at Constructed Well Depth <br /> COMMENTS' <br /> PE SC Amount Reyei'veb Dale permit! Invoicc4 Well IDII <br /> Codes Info Remitled C sh By Service Re ucst N <br /> 96,Q32 111 <br /> /E'FfD 43-02-O8" MASTER WATER WELL PERMIT <br /> 5n12002 <br />