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WELL 1 PUMP PERMIT <br /> 304 E WEBER AVE 3 FL-STOCKTON CA 95202 - (209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R FROM DATE ISSUEDCALL 209 953-7697 FOR INSPECTIONS �Z��NON-REFUNDABLE PERMIT ' �� Srn t�F Tk 1:77 <br /> i JOB ADDRESS I P 3 z 'rAPN — PARCEL SrFICRASS STREET ✓ r• "I '''fOWNERNAME �� q3 + zCITVISTATEIZIPOWNER ADDRESS PHON <br />` CONTRACTOR (L O�+Al / 1,T <br /> n b CITYISTATEIZIP__T t��/� 1 <br /> CONTRACTOR ADDRESS f P <br /> CONTRA �i�y PHONE <br /> f <br /> F II �I'//r/ !' <br /> SUBCONTRACTOR s A L <br /> 11 N CITYISTATEIZIPAll <br /> [ <br /> SUBCONTRACTOR ADDRESS `� .!O DA <br /> I �NUMBER 4 <br /> LICENSE C-57 ❑hC-61 ❑D-09 ❑Other ' IVII III <br /> do - <br /> �` Y Township Range <br /> GEOGRAPHICAL INFORMATION: Coordinates X ] ❑Industrial ❑Water Quali i .n�1 �hti �n <br /> 1NTENDED SE ❑DomesticlPrivate ❑lrrigationlAgricultura , <br /> ❑Public Water System ---- ._. - a,....- --"'. - --o _mei rnle m.rl U " <br /> 3 k of borings <br /> TYPE OFA WORK ❑New Well ❑Replacement Well ❑We11 Alteration/lvlodi6cation �of❑FOgs a ❑Geotechnical <br /> ❑Monitoring We11(s) <br /> #of wells Soil Borings)�� <br /> r ❑out-of-Service Well Renewal ❑Gross Connection Repair <br /> - ❑Out-of-Service Well <br /> ❑New Pum ❑Pum R lacement ❑Pum R air <br /> r �` <br /> WELL CONSTRUCTION I r ❑push Point ❑Other <br /> Auger Cable Tool <br /> Drilling Method ❑Mud Rhotary ❑Air Rotary m diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> �E Proposed Well Depth ft Excavation�� ft <br /> f ❑Conductor Casing in diameter 1 Conductor Casing Depth <br /> ❑Steel ❑Plastic ❑Stainless Steel ❑Other- <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched�___ ❑Sand Cement sack mix 17 gal water <br /> Grout Seat Depth - ft *eat Cement(94 lb bag/5-10 gal water) ❑Specs on File ❑Specs Submitted <br /> 0Bent66ite(20%solids) ❑Manufacturer Spec%solids % Name <br /> 11" mped Free Fall 13 Other <br /> ❑Retardant 1 Accelerator(name) <br /> Grout Placement Method <br /> r PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other in [3 Christy Sox ❑Stove Pipe <br /> F 1-1 Concrete Pedestal Dimensions:Width <br /> ft Thick <br /> PUMP C3Subnjiersible ❑Turbine 13 cdxip�_ <br /> HP-Pump Set ft Standing Water Level ft <br /> RD C <br /> F I HEREBY CUNT YTHAT I ORDINAN ESESTATE LAWS,THIS <br /> AND RULES AND REGULATIO SE i WORK <br /> ALSOWCERTIFY THAT MY REQUIRED L CENSE IS <br /> CURRELL BE DONE IN ACCO AN E WITH SAN <br /> JOAQUIN COUNT <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH AL <br /> ' WORKERS COMPENSATION LAWS. U IRED FOR INSPECTIONS <br /> MINIM 24 HOUR ADVANCE N 'T � ' pp <br /> TITLE v DATE ( 7 <br /> SIGNED <br /> ! IM: L 1 <br /> IfM <br /> �fF <br /> 1 �! <br /> 1 IM <br /> D E P A R.T.MM E NX-U-S_E-C N-L Y 1f <br /> !L a. _GC �0Area Employee lD# - <br /> Applicatron Accepted By <br /> ❑ SPECIAL Well Permit-- <br /> Grout inspection By <br /> it [3 WAIVER Received <br /> I Pump Inspection By Date <br /> . � <br /> Constructed Well Depth ft <br /> COMMENTS C:Ef F�o•.�C9- I t R?a T'1�1 <br /> c <br /> I` Permit! <br /> k PE SC Received <br /> !Amount Date # WellCodes Info BCgq� itted Service Re uest# <br /> 43- (mooqLi <br /> t � <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> 1/27/2005 <br />