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sMhal Scan LfJ13111 AV \L WELUPUMP PERMIT if SAN JoAoui, CcUNTY EwARoN meNTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVEMM - STOCKTON CA 95205 - (209) 4683420 NON-REFuNDABL�e/PEFtmrr CALL 209 953-7697 FOR INSPEGTKM EXPIRES I YEAR FRoM DATE ISSUED Joe ADDRESS JUN D � Cd ' ///�� V `1� ' r`1- � r" 1 C N 3 F//7(P CROSS STREET TYPE OF WORK New Well Replacement Well Well ARerabon/Modification Other AP ;040PARCEL SIM LAD U$E APPLICATION 91 OwwER NA .\NE ._#ofwells .GeoteCnical Out- Pice Wei -Of-serviee Welt Renv a! C?;z,6 ffmction ; m Pump New Pump Pump Replacement ump Repair Raise Well Casing Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other (1 Proposed Wap De;Pth ft Excavation in diameter Open Bottom Gravel PaddGravel Size_ in diam OWNER ADOREss VCTTY/SM- COnductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thidmess/Gauget/ASTM Schad Steel Plastic Stainless Steel Other CONTRACTOR U Grout Seal Depth ft Neat Cement (94 Ib ba9r5-10 gal water) Sand Cement sack mbd7 gal water S V NTRACTOR ADDRESS Grout Placement Method Pumped Free Fell Other Retardant / Acoelerrtor (name) fid CITY/STA -1A G S BCONTRACTORN/H/I Concrete Pedestal Dimensions: Width_ ft ft Thkk in Christy Box : Stovepipe _ _n%Iq V I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS SU ONTRACTOR ADDRESS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM W COMPLIANCE WITH ALL WORKERS COMPENSATION CRYIST/AT�I/JZP LAWS. LICENSE C-57 %1 D-09 Omer N `-r `r"ty 0 E7rnItATION DATE m 0 'o T a GEkxItAPNrcAL INF ATION: Coordinates X Y Township _ Range Section_ INTENDED USEDomebtic/Private Irrigation/Agricultural Industrial Water `Duality Monixing SD6 SanpOn9/ChatadpflZation Public Water System tf doe'" hrn owner •1 TYPE OF WORK New Well Replacement Well Well ARerabon/Modification Other MatitonngWell (s)SodBoring(s) Aofbak� ed bor1n9' ._#ofwells .GeoteCnical Out- Pice Wei -Of-serviee Welt Renv a! C?;z,6 ffmction ; m Pump New Pump Pump Replacement ump Repair Raise Well Casing Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other (1 Proposed Wap De;Pth ft Excavation in diameter Open Bottom Gravel PaddGravel Size_ in diam COnductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thidmess/Gauget/ASTM Schad Steel Plastic Stainless Steel Other (, Grout Seal Depth ft Neat Cement (94 Ib ba9r5-10 gal water) Sand Cement sack mbd7 gal water S Berflonite (20% solids) Other Grout Placement Method Pumped Free Fell Other Retardant / Acoelerrtor (name) PEDESTAL Installed By Driller . Pump Contractor Other 4\ Concrete Pedestal Dimensions: Width_ ft ft Thkk in Christy Box : Stovepipe _ au —up Submersible Turbine Other HP Pump Set ft Standing Water Level ft V I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM W COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. iM� 2d HN NOTICE REQUIRED F`OpR InNSPE� ASE CALLD(209 9 -7697 �/6E 0 ATE POW— RFCEI�1 � APR 13 5pN JOAQUII E"RONI H4EXLTnA DEQ Application Accepted By Grout inspection By Pump Inspection By Soil Bonng Inspection By COMMENTS E ARTMENT S ONLY Date 7Area Employee ID#_G��i !� Date G SPECIAL Well Permit Date ^ WAIVER Retelved Date Constructed Well Depth }l CPJ 1S VC Y!D 12 WELL Nl1AlP PERNR