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e r WELL / PUMP PERMIT t: <br />f SLN .IOAQL'LN COUNTY Es" 1R(p:a ENTAL HEAvi'H DEPAAT.mk*,T 690 E wn Aims STREET - STocKTon CA 95M - (289) 468.3426 <br />3011 ADDRESS R 8'Z S/ L11494121 6 Cft sfif.�tJP�/, Z_ �4 ��tJ, C' <br />CROSS STABLY JWE4 `, `! �•r APN O' 7W J K/1 NACEL SIZE e � —` <br />OWNERNAME /*N VQ� ECS dLA-11��'i(/ O/�.�5 �%P�Iw.,,_32!25`13 3 <br />OWIERADDRESS tl..dV CfT1'IST.%TELZIP `" r �� eq �j 5? JGG3Aa• <br />CO%MACIOR G % !N�//G /L7(�G�iy - --" pito%E <br />CowwwIORADDRE56 - CuY/S'rATEMP <br />SUBCONTRACTOR _ PHONE <br />SUBCONMWTORAnDRESi^ Cff1/STAfTJ7APP/_—__ <br />LICENSE 0C-5;• �6_61 0D-09 ❑Other NtvIBEA <br />GE0GsuFHICALINTORaL1Cl0\: Coordinates Y Y--.----- Township_ Range Section <br />INTENDED USE 0 Dotmztic.Privatc rrigatinaAgricultural 0Indostrial 0 Water QualityMoakring 0 Soil Swrrptin?:Cha acteritation <br />Cl Public Ware, SyVern <br />R'ddim=Bce:(Yn W'=S)­.Vm, CeuO.%-. or Phar Nuc'r <br />TYPE Or WORK G `s:ew W.N 0 Replacement Well 0 Well AU:ratimuModitication 0 Test Hose O Other _ <br />0MonitoringWeli(s) ncmtertfWeas ❑Soil Borings) rwmt"r..fHnnr'F, 0CkDtechnical amnc•,.tw•trtt: <br />I DwTuedon 0Out-0f-S';vice wow" D Ota-0f-Scnic:. Well Rcu.:aal <br />WELL CONSfRUCTIO\ <br />Dry -Method 0 Mud Rotary 0 Air Rosary ❑ Augcr 0 Cable Toot A Push Point 0 Other <br />Proposed Well Depth P Excavation in diameter <br />D Open Bonom Cl Gtacel Pack i Gravel Sine in diamaa ! <br />0 Conductor Caging in diameter / Conductor Casing Depth it <br />Well Casing Diameter—in Thickness'Gauge:ASTM Schell <br />O&M O Plastic 0 Staide=s Swel 0 Oder <br />Grant Seal Depth ft 0 \'cat Ccn=t .Y410 bag:' 5-10 gal nuts} <br />0 Sand Ccmalu sack wiv, 7 gal water <br />0 Bemoaite (2tyie solids) 0 Manufac:urr Spec °: solids `:o <br />liana __ 0 SFxs on Fil: 0 Specs SuhmiDed <br />Groat PSaceaseat.Methed fa •d 0 Frcc fall 0 Other <br />0 RetardaN: Accclawar (name) I <br />PEDEFFAL Installed By a Ortiter 0 Pump conaw..or <br />0 Oder <br />0 Concrete Pedestal Dhneaslons: Width—it Umph— <br />ft Thick in 0 Chrism B. 0 Stme ' <br />Pump xTurbine DOther HP <br />PtrmpSa fr StartdiagWatcrLeccl _ fi <br />SYELt. DtsrRUCllO\ 0 Open Bottom D Gravel Pack Cl Vircnscd <br />0 Othzr <br />Well Diametr_ in Totai Depth N Depth to :Pater <br />it 0 Casing to be Perforaud fmnr it to ft j <br />$eating Nfaterial 0 Neat cement (94 16 bag:'S-Ingo) prefer/ D Sand Cemcak <br />wck mix 17 gat water 0 Bentonite Pellets t <br />' <br />C Bcnmiw (2W. solids) 13 Nhmufacturer Spx % solids —_ 4o <br />Name 0 Spocs on Filo D Spurs Sohroined <br />Piacetaeat Method D Pumped 0I = Fail 0 Other <br />` <br />0 Complcto Kith MushtoomCap ft below gra& <br />0 Com lc:e to Existing Surihce Pad <br />V, <br />RE PAYMENT <br />�elve td <br />APR 0 3 2018 <br />/ HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI THE WORK AML BE DOVE LV ACCORDANCE WITH SkN"'V JOAQUI <br />JOAQLTN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. 2 ALSO CERTIFY THAT MY REQUIitED LICENSE L� ESR � CQ(�N <br />CURRENTAND ACTIVE WITH THE CALIFOMI A CONTRACTORS STATE LICENSE BOARD A_%D THAT I ANI Lti COMPLIANCE WITH AAEAw0pimnL7-H p p EF �n' <br />AR <br />SIGNED TITLE ,WA/I � DATE 3/d3l(� <br />CEiVEp <br />IRI <br />b ^1 2018 <br />NMENTAL HEALTH <br />VIT/SERVICES <br />Application Awepted By—� �„!! Date .. Area y/ t1q- Employee ID# W6 ) 4(_J <br />Gmn Inspection By Date 0 SPECIAL Well Permit J/ <br />pump inspection By__ _ Datc i7 WAIVER Received <br />Destruction Inspection By— _ Dau. Constructed Well Depth _. it <br />Cr11) 43 -0L -1X16 wEB VVel! Permit and Dccljrat Jai; <br />91111 ..W7 li00 D/It-� <br />