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WELLIPUMP PERMIT <br /> SAN JOAQUIN COunTr ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAeT HA=TON AVENUE-STOONTON CA III-(209)ase-ao <br /> NON-REFUNDABLE PERM —CALL CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> FAvomw // e V�FRM AN P-ywsm•> Cn,rds 5TVI'igyAJ/9SZt76 <br /> GGE 5w8 I PAReeLSulA41rrsP115DwGGAtIHt G2Af 97w EGeGIJrrlc to aLW k4NY PnoNS475 ZVV -3'40L rtcl>c/y613oY7jno,ATmS Glq 9�d-( 7iAn1 `c?q)7-1 <br /> /4SGt9a OruuraG7 [..p Pm E$ 30A90 Oyiy.W 571�66T CMISTATeP[P WOE TSMJCRAnF6NN 4S� <br /> SwcconitAcToa -- <br /> PHONE <br /> SueedRMCTOR AOORIas CRYtSTATETIR <br /> LICENSE CSl C$1 D09 Other n NUMII-�38 IN flo Exasul DATE,/�P/�I <br /> GEOmAPNNALINFMMIM: Coordinetaax3'9: ( g,89Z Y—IL1-y$2111• TOWm Z RL • S•NonLC <br /> NP_ Iq �X{ _ <br /> In DED Use DME1110'1i'rivme Imgation/AgdcullUM Industrial Wmar Quatlty Monitodng XSoUSampling/Charaderimllan <br /> PWsc WINE,System <br /> rcmn.�,tn.monr em ,m, a w e <br /> TYPE OF WORN New Well Replacement Wetl Well NleratioNModdutlen Other <br /> Monitoring Wallis)_A of VsMS Shc Bodng(s) ad"V- /Geotechnical /a/ "'wale <br /> Out-Of-Service Wall OutOffSarvk:e Well Renewal Cmsat nnsction Repair <br /> Nsw Pum _ PUM2 Replacement Pump Repair Rasa Wetl Cuing <br /> WELLCONITNUCTION <br /> Drilling Named Mud Rotary A,Rotary Auger Cable Tad Push Point Other <br /> Proposed Wall D.Plh/D -20 ft Ezraystbn a In dammer Ow Badom Graven PaWGrewl Sizer In diameter <br /> CendUctor Casing In diameter / Conductor Casing Depth ft <br /> Well C•mng Diameter_In Thickness/GaugEVASTM Schad Steel Plastic: Stainless Steel Other <br /> Grout Sam Depth—ft /Neat Cement(94 Ib beg3-YO gat water,) Sand Cement asck marl/gm wens, <br /> Bentonlle(20%adide) Other <br /> Grout Placement Mamod Pumped Fore Fall tOther7e/wt /ERmaN.m/Acularatpr(name <br /> EIRCAL&L Imtalted By Other Pump Contractor Other <br /> Coner.b P.da.W Dimanelom:Widlh_R Length ftThli Chris Box Saw Pip. <br /> S-temia da Turbine Other HP Pump St ft Standing Water Level h <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 /> WORKERS COMPENSATION LAWS.711J HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> Smmn � TITLE PlP-DJtta ENG2/N6612 DATE 13—3liLY -2p/} <br /> CEIVE® <br /> ppYMENT UL 0 7 2017 <br /> RECENE ONMENW HEALTH <br /> JIJL 13 2 RMIT/SERVICES <br /> SAS,IOJ,QUP+� <br /> EwRON% <br /> HFJ,LTT7 DEPART <br /> ——— N 11 1 1 - I I I I FF <br /> E PSA TYENT U E CINLY <br /> Appti.11m AcceFled 8 PUMAAlae Employee S <br /> Grout Inspection By Date ❑ PECIAL Well Permlt� <br /> Pump Inspection By Date ❑ WAIVER RI Ceived <br /> Soil Boring Inspection BY Date Comtroetlad Wag Depth ft <br /> COMMENTS <br /> PE Info Codes R.caN.tl C Romi Nd Dm S.rek••R u•ma p <br /> Mwka0 WeII IDs <br /> d <br /> �3 Z <br /> VNQ. <br /> 4x012 WELL RUN'IERNT <br />