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WELL / PUMP PEit virr <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"° FL - STOCKTON CA 95202 - (2091469-3421 <br />INLIN-KEFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�J ST EE CITY'/ZIP 0 T (462-12 <br />CROSS STREET APN Ulcer US�� —1�( PARCEL SIZE ' LAND USE APP'''"1```"`ICCCA7ATioN # <br />OWNER NAME <br />PIfONF wav c� aJ�w) <br />OWNERADDRESS CITY/STATE/ZIP % L <br />r <br />CONTRACTOR <br />PHONE <br />CONTRACTORADDRESS_ .� � CITY/STATE/ZIP <br />SUBCONTRACTOR �h _ _ PHONE • i I/t <br />❑ D-09 ❑ Other NuMBFA e! .(1U((0 EXPIRATION <br />GEOGRAPIRCALINFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE Domestic/Private ❑ Irrigalion/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling1Ch2racterira60n <br />❑ Public Water System <br />ifdi Rami from Owner: Wa.r ysum ame Ccmm t Nme ar = um <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Ahcration/MOdilicalion ❑ Test Hole ❑ Other <br />❑ Monitoring Well(s)_.N ofwells ❑ Soil Boring(s) s ofoonagr ❑ Gnotechnical a ofbcriaar <br />I <br />❑ Well Destruction ❑ Out -0f --Service Well 13Out-OF-ServiceWell Renewal <br />❑ New Pum Pum Replacement ❑ Pump Repair ❑ Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth R Excavation, in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ in Thickncss/GaugdASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Dcpth ft p Nut Cement (94 th hag /5-10 gal water) ❑ Sand Cement sack mix 17 gal water <br />❑ Bentonite (20%so] Ids) ❑ Manufacturer Spec % solids _ % Name _ ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Fra Fall ❑ Other_ ❑ Re:ardant/Acceletalor(name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Convector ❑ Other <br />❑ oncrete Pedestal Dimensions: Width_ 0 Length_ R Thick in ❑Christy Bax 13 Stove Pipe <br />PUMP Submersible ❑ Turbine OOther IIP Pump Set R Standing Water Level IM tl <br />1 HEREBY CERTIFY THAT l 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 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT F AM IN Cn%IPI.IANrR WITH sr I <br />Th <br />r <br />�h <br />n <br />-Ei <br />Application Accepted By <br />Grout Inspecti <br />DEPARTMENT USE /ONLY <br />--� Date /L` 13(0 <br />Date__ <br />Area Employee ID# 5 3 E r <br />/ <br />13 SPECIAL Well Permit/ <br />Pump in don t3 <br />/,� <br />Dale /�a�.%d.G <br />13 WAIVERReceived <br />Destruction Inspection By <br />_ <br />Date <br />Constructed Well Depth A <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Into <br />Ch -k#/ <br />Arrjunt Date <br />Remitted <br />PnrmiU Invoice# WeIIIAt <br />Service Request # <br />EHD 41 -a2 -W[ <br />M, WELL PUMP PENMIT <br />