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Ty,"!l, S[a, l-}y_ 1-7 o we \ <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTA1.HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT 41�) /C L 209 933.-7�6/9�77 FF�OR Wa mons PIRES 1 YEAR FROM DA Issueo <br /> Joe ADoREss u C 1 ► /t/> rW Cmr2]P O � ( zl o <br /> CROSS STREET AQN 'PARCEL SIZE kw-F-; <br /> USE APPLICATION# <br /> OWNER NAME Y/.6{- / /� a <br /> OWNER ADDRESS O /i a �/� A r,4/ l� <br /> CONTRACTOR T / <br /> CONTRACTOR ADr,� / Wngy,� 4STA /� <br /> SUBCONTRACTORV I] <br /> 1 <br /> PHONE h -� <br /> SUBCONTRACTOR ADDRE�SS/_ n CnY/STATZrZIP V <br /> LICENSE C-57 ►/C-61 D•09 Other NUMBt � � FawIItATroN DATa <br /> GEOGRAPWCALI zrQ4ATION: Coordinates Y Township_ Range Section— <br /> 'INTENDED USE V Domestic/Private IrrigatioNAgricuttural Industrial Water Quality Monitoring Sol Sampling/Characterization <br /> Public Water System p� <br /> i If different from Owner' water Systm r4ame Q01na Flom or F%"Nuffdw <br /> TYPE OF WORK V41ew Well Replacement Well Well Afteration/Modilication Outer <br /> Monitoring Well(s) #of wells Soil Boring(s) z of borings Geotechnical Yofborings <br /> hut-OfService Well Out-Of-Service Well Renewal Cross-Connecdon Repair <br /> V Jew Pum Pump Re lacame , P,mip Repair Raise Weil Casing S <br /> WELL CONSTRUCTION 0 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other, f�\ <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Peck/Gravel Size_in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel er Plastic Stainless Steel Olt-7 C <br /> a <br /> Grout Seal Depth ft Neat Cement(94 2 bagrSlO gal water Sand Cement sack mb17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fail Other Retardant/Accelerator(name) <br /> PEDESTAL InsWled By Driller .Pump Contractor Other <br /> Co trete Pedestal Dimensions:Width it Length It Thi!c in ChrlaLy Boz Stove Pipe C^ <br /> IPUMP Submersible Turbine Other--.---- HP.__ PUMP Set-nLft Standing Water Level k� n <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS A <br /> CURRENT AND ACTIVE WITHtYK CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL -� <br /> WORKE SATION S �� <br /> MI U 4 HOU ICE REQUIRED I S/PEC�TTIOON/S�-P E CALL(209)3f7 97 (�1 <br /> SIGNED T - t L'C! r /of DATE / GJ r.�, ^� <br /> �RECEENT <br /> VEL) <br /> SAN 24 2017 <br /> 074 <br /> SA"JOA QUIN CO <br /> H� E� � <br /> r <br /> IVEI—D <br /> .SAN 11 2017 <br /> PRM T SERVICEENIAL SLTH <br /> � 9f#L"o,1-1 <br /> EP TMate USE NLY <br /> Application Accepted By Date Area Employee ID#- �� <br /> Grout Inspection By , �� Date 0 SPECIAL Well Permit <br /> Pump Inspection By ¢'( �- L/L— Date to S(0 1( I L -. WAIVER Received <br /> Soil Sonng Ins'pection By Date Cona&u¢sd Well Depth ft <br /> COMMENTS/�"�L. �� -t <br /> �P k 4 ` <br /> PE SC Received Ch Amount Date PernlW Invoice# Well IDS <br /> Codes Into B sh Remitted ServiaRequest# <br /> .r30,2 <br />