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~ 'A(1�iC'/��et SHFON W E:6 L106 'E 'IDO anvil paAI;3;� <br />WELL/PUMP PERMIT <br />SANJoAouiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1858 EASTHAZELTON AVENUE-STOCKTON CA 95205 - (209) 411 <br />N-KEFUNDABLE PERMIT GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />AoDRESS 22828 E St Rt 12 Hwy CITWZIP Clements, 95227 <br />SS STREET Johnson R d APN OL3—/4i33 PARCEL SIZE 4�•LAND UsE APPI-ICAnON # <br />ER NAME Terry R e m i t z 1 �r+R PHONE <br />ER ADDRESS 1250 Hilliker Place _ CI7y1STATE/ZJ'iverT2ore, CA 94551, <br />TRACTOR Purviance Drillers, Inc. <br />YRACTOR ADDRESS P . O .Box 64 <br />tCTOR ADDRESS <br />X1 C-57 I' C-61 <br />I D-09 a Other. <br />"09-887-3554 <br />CRY/STAT Emp Linden, C A 95236 <br />Ctry/STATEMP <br />NUMBER 3 7 7 9 2 3 EXPMAnON <br />GE4DaRAPNICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE Il Domestle/Private Irrigation/Agricultural D Industrial -I Water Quality Monitoring U Sal Sampling/Charectenzation <br />I I Public Water System <br />IrdiRerern (M Ow•rer: WaterbyslervNiame : a Nar® or Phom Numbw <br />TYPE OF WORKVats well Replacement Well -_ Well Alteration/Modification Other <br />n MonitoringbVel(s) ftollwells r Soil Borings) Acn odnlls I Geotechnical YGr tieftrlgB <br />I I Out -Or -Service Well F Out -O` -Service Well Renewal r 1 Cross -Connection Repair <br />i.i ---up - rmnp rtern—FICnt 1. r'Ump Kepalr LKalse `Neil ii asing <br />WELL CONSTRUCTION <br />Drilling Method )(IAud Rotary L Air Rotary J Auger U Cable Tool - Push Point 11 Other <br />Proposed Well Depth4150 It Excavation 1A in diameter )eOpen Bottom J Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in ThicknessiGaugeiASTM SchedI I Steel a Plastic C Stainless Steel n Other <br />Grout Seal Depth am At ift 71 Neat Cement (94 /b bagi5-10gal water) I I Sand Cement sack mlxl7 gal crater <br />n Bentonite (20% solds) I Other <br />Grout Placement Method Xumped " Free Fall D Other 11 Rerlardan(f Accelerator (name) <br />PEDESTAL Installed By . Driller :1 Pump Conlreclor D Other <br />U Concrete Pedestal LDlmansions: Wrdth ft Length ft Thick in I I Christy Box U Stove Pipe <br />PUMP U Submersible— Turbine I Other HP Pump Set ft Standing Water Level It <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 />WORKEIa+BOMPENSATION LAWS-, <br />MIN UM 24 ANCE NOTICCJEE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED_ T,11COrP Secretary DAT,10/3/17 <br />rn <br />A <br />a <br />b <br />Q•yt`r.f I-� <br />C- rf l <br />C -WI. <br /><_t.D M <br />Application .Accepted By <br />jG a Sk C 11� I Grout Inspect on By <br />wy •f Pump Inspect on By <br />N� Boring In�s.P/e�ctlp�rt OY <br />COMM�NTS I�1<NNII <br />EPARTMENT USE ONLY <br />Date i2zArea I Employee I D# LI <br />Date i D SPEGALWell Permit <br />Da :1 WAIVER Received <br />Date Constructed Well Depth w ft <br />oa <br />4=112 (U t/— / %� n � V Y ✓ 1 /� / I /l�) r ` _ IRINP PER M.T <br />II O i J AJI. U/l. I <br />Z'd trL9SZ9260Z (n vt/� u�fs✓ja 1 jC] eoue /und dt£:ZO L 6 CO 100 <br />