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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 N EAST HA7ELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />nvrv-rctrunuAULt f-hKMI I <br />L AkLL [uy yD3-/Dy! FOR INSPECTIONS 11 YEAR FROM ISSUED <br />JOB ADDRESS 16 3-71 <br />�tZX�P/yXIZ5/�� /'/�DATE <br />G vc ^y CIl'1'%iJP `� v'y G V I C - / ✓ C-. J <br />� 1 <br />CROSS STREET <br />OWNER NAME <br />P <br />\ r <br />� N P EL Sly ND USF�APPLICATION <br />(/♦r7�4� L/{ <br />/' ^/ <br />OWNER ADDRESS <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Pant Other <br />�] l / <br />CONTRACTOR ADDRESS 70 <br />SUBCONTRACTOR N <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 VC -61 <br />LA <br />D <br />0 <br />0 <br />m <br />m <br />-0 <br />V 1v <br />V <br />1 <br />GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE V Domestic/Ph ate Irrigation/Agncuttural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from OwnenWater System ar" eMe a PnWe NuMber <br />i <br />TVPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) 9atwells SoilBoring(s) 9ofborings Geotechnical zofborings <br />I� <br />Out-OfSemce WeOz t-Of-Ser:^ce `welt Renew2? C. -`c CD -r:=-"-- Repair <br />Naw P:.n L� rn Re lacernei ii Pum Repair Rake Weii Galin <br />WeLL CON�irlucTl N <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Pant Other <br />(O� <br />\' <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thdmess/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bagIS-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Aoceferator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width _ ft L ft Thick in . Christy Box Stove Pipe <br />PUMP Submersible Turb ne Other HP Pump Set U R Standing Water Level IVU ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />N <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />r� <br />CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />^ <br />v ` <br />MINI�H UR NCE TICE REQUIRED NCE TICE REQUIRED FO INSP�E%C�T//IO��NS - PLEASE CALL (20,91953-7§97 <br />SIGNED TITLE�Y F l.C��� DA <br />EP RTMENT U,6 E O L) <br />Application Accepted By Date <br />Grout Inspection By _ Date <br />Pump Inspection By �V/RS tf`�"/Yi �71.Z _ Date <br />Soil Bonng Inspection By _ Date <br />COMMENTS <br />EMAY 16 <br />2017 <br />S■■■■■■■■■■■■■'R <br />SENSE■■N■E■■■WM.-Til 14MEN-rk <br />A.0� lrrplciyeel._6t�0 <br />WAIVER ReCelved <br />Constructed Well Depth <br />PE SC ! Received ! k�Cheek#Y Amount Dau PerrniU Invoice 0 Weill ID# <br />Code Info B ash Remitted Service R tl. X <br />HC : rJ6 WELL /PUMP PERMIT <br />10 12 <br />