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`,J 2 = 3c� <br />R WELUPUMP PERMIT <br />11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />DE ARTMENT SE ONLY <br />hi, Date v <br />Area Employee ID#jt4j <br />JOB ADDRESS I-MDOm <br />Date <br />❑ PECIAL Well Permit <br />Pump Inspection By <br />Date <br />CfTY/ZIP <br />❑ WAIVER Received <br />D <br />Date <br />Constructed Well h ft <br />COMMENTS J <br />AAD <br />�— <br />CROSS STREET <br />APN RCEL SIZE _LAND <br />USE AP ATION # <br />a <br />I f 60f <br />OWNER NAME H't� <br />PHONE <br />u! <br />PE Sc Received <br />Codes Info B <br />`` <br />OWNERADDRESS / I D t <br />RSI f VVF CITY/STATE21P <br />WeIIID# <br />OWjJ t <br />C.A`�IV <br />l)✓1 f WfA I DrAt I v, <br />� I <br />CONTRACTOR /t/y�CZ Y] <br />� <br />PHONE 0Z <br />!//. <br />ADDRESS mot I SY I tif-I, <br />Aye'`/ p <br />r t �+ e U� V A CITY/STATEIZIP <br />EHD43-06V <br />4130/12 l�.J� <br />LL ._ <br />rV ��7-C� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITN/STATEIZIP <br />LICENSE C-57 L C-61 Li D-09 <br />U Other NUMBER 1 7� <br />EXPIRATION DATE - 1 12- V 1 Q <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y Township _ Range Section <br />INTENDED USE 1)KDomestic/Private 7 Irrigation/Agricultural ❑ Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization <br />U Public Water System <br />If different from Owner. water 6YStern Nam Contact Name or Prione umber <br />TYPE OF WORK p(' New Well 13IReplacement Well U Well Alteration/Modification U Other <br />❑ Monitoring Well(s) #ofwells ❑ Soil Boring(s) #ofborings D Geotechnical #ofborings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u ttaise Well <br />Drilling Method )(Mud Rotary C Air Rotary C Auger 7 Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth -21120 ft Excavation � g)— in diameter u Open Bottom U Gravel Pack/Gravel Size in diameter <br />FI Conduct r Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in /TThhic rrss/Gauge/ASTM Sched nSteel n Plastic rl Stainless Steel -1 Other <br />Grout Seal Depth r 4Y� C Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack miul7 gal water <br />Bentonite (20% solids) L Other <br />m <br />Grout Placee Method Pumped D Free Fall C Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 3 Driller C Pump Contractor 7 Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box D Stove Pipe <br />PUMP ❑ Submersible? Turbine C Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE <br />�PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN CURRENT AQY /D ACjE IS <br />11�E (WITH TWCALIFORNIA CONTRACTORSTATE LAWS, AND RULES STATE LICEIONS. I ALSO NSE BOARD AND THIFY AT AMT MY REQUIRED N COMPLIANCE WITH ALL <br />FOR INS�P�EC IONS`1- Loi CALL (209) R58-7697 <br />E L1�YY�/1 I 1 �_v► DATE <br />z <br />�MENT <br />6 0 2 2017 <br />AQUpy co2OIVMEUNTy <br />DEPaRAL <br />T NT <br />r <br />Application AcceptedBw <br />DE ARTMENT SE ONLY <br />hi, Date v <br />Area Employee ID#jt4j <br />Grout Inspection ByAlk"✓� <br />Date <br />❑ PECIAL Well Permit <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well h ft <br />COMMENTS J <br />AAD <br />�— <br />Z-9-;* % <br />PE Sc Received <br />Codes Info B <br />Amount Date <br />ash Remitted <br />Permit/ Invoice# <br />Service Request# <br />WeIIID# <br />EHD43-06V <br />4130/12 l�.J� <br />LL ._ <br />rV ��7-C� <br />01�11,X f�/�jn.�zn6r1jL/PUMP PERMIT <br />�C� �--C 7 L VTi <br />