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WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EASE M. AIN STREET - STOCKTON CA 95292 - (201) 46 3429 <br />NON-REFUNDABLE P%EGR.-OUT <br />EXPIRES I YEAR FROM DATE ISSUED <br />/ /,/ / <br />of O S/ G� y �(p ti <br />- �: L/iyD CAI, <br />JOB ADDw:sc _ _ . <br />STREET r �"�'" �//�D <br />, �.�, <br />AI --N O O / PARCEL SILE <br />CROSS _ <br />/��CJI- <br />' / _9 _ <br />T <br />ONNERYAMS '/{7,' ✓ �y�� ` D����N 0�1 NE ��/ ��/�� <br />❑ Steel ❑ PIastic ❑ Stainless Steel ❑ Other <br />Groat Seal Depth fl _ ❑ Ncat Cement t94 Ib bag / 5-10 gal "mer) <br />OWNER ADDRESS / V /,/�� <br />CITY/STTAAATTErZJI` <br />S�� /" ' PHON/E// � <br />CONTRACTOR 7 w <br />CONTRACTOR ADDRESS <br />%/ <br />CITY/STA.Ibl <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS _ <br />CITY/STATETLIP <br />LICENSE ❑ C-57 C-61 ❑ D419 ❑ Othcr <br />NUMBER EXPIRATION DATA. !J <br />i:FM.RAPNrf AL INF( Xl ATH . C.-,M..L- X Y <br />TOWR3a1D_ Ramme Section <br />INTENDED USE C3Domestic/Privatc Itrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring C3iw <br />Soil Sampling/Charactertion <br />` ❑ PDNic Waley System <br />If difr—t &-- Lt, u Wer S)—n Xa= ('oNacr Vwe a Ph.—Numb. <br />TT PE OF WORK ❑ New Well ❑ Replacement Well O Well AlteratiomMadific tion ❑ Test Hole ❑ Other__ <br />❑ Monitoring Wells) ooio6ef Of `red3 ❑ Soil Borings) oWOb`r of 0 Geotechnical <br />jy�ye11 Destruct ❑ 0ut-Of-Service Well ❑ OW-0f-Scmice Well Renewal <br />WELL CONSfRU 1 X <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary Cl Auger ❑ Cable Tool ❑ Push Point ❑ Other_ <br />Proposed Well Depth ft Excavation in diarmtcr <br />❑ OpeR Baton ❑ Gravel Pack / Gravel Si.. in diameter <br />❑ Conductor Casing in diameter t Condmwr Casing Depth fl <br />Wen Caslag Diarrcter _m ThiclamwGaugrJASTM Schell <br />❑ Steel ❑ PIastic ❑ Stainless Steel ❑ Other <br />Groat Seal Depth fl _ ❑ Ncat Cement t94 Ib bag / 5-10 gal "mer) <br />❑ Sand Cernem sock mix / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufscn= Spec % solids _ % <br />Name O Specs on File ❑ Specs Submitted <br />Great Placement Method ❑ Purvtped ❑ Free Fall ❑ Other <br />❑ Retardant i Accelerator (name) <br />PEDESTAL haanlied BY ❑Driller ❑Pump Contractor <br />13 Other <br />❑ Concrete Pedestal Dhmusious: Width R Length -3 <br />Thick in ❑ Christy Box ❑ e <br />PUMP mmsible Turbine ❑ Other HP <br />Pump Set , 1l St i brig Water Lcvd ft <br />WELL DmRucTl N ❑ Open tlostom ❑ Gravel Pack ❑ Uwased <br />❑ Other _ <br />Well Diameter__ in Toni Depth ft Depth to Water <br />ft ❑ Casing to be Perforated from _ _ fi to _ ft <br />Seallog Material ❑ Neat Cement (94 1h bag / 5-10 gal water) ❑ Sand Ceaeni <br />sack mix i 7 Sal water ❑ Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % <br />Name ❑ Specs on File 0 Specs Submitted <br />Placement Methed ❑ Purttped ❑ Free Fall ❑ Other <br />❑ Complete with Mushroom Cap ft below grade <br />❑ Complete to Existing Surfacc 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 ACTIVEVVITU VIIE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMffVW*A2 <br />1101-R ADS' INCE NOTIC Y RF( -)l IIRt t1 FOR INSPF( TIt­)NS <br />SIGNE)r� TITLE G�/V DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump InsperotioR By <br />Destruction Inspection By <br />CONO EN S <br />:HENT U 0r7.Y <br />Date Area Employee SDk <br />Date <br />Z 0 SPECIAL Well P.Mit <br />Due 0 WAmm Received <br />Date Constructed Well Depth . R <br />Jtll 13 2018 <br />JOAQIJ <br />D�NMFNTUNry <br />I AlR ANT <br />CHI) 4.i ZAM WhB weft rermn am trectaranaD.aoc <br />9/11/2097 <br />