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�J <br />WELL / F'Ui rP .P:E Rmrr 'f 'g0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON_RFFIItuneal V 1PIP—Ir / A r I <br />/ �J / - --- --- -- --•••••••••-.........• u/�'�'/../�y.�1 Ir.AR r.uirl"A 1 C 1JJUl.0 <br />JOB ADDRESS y 3S / (/. (j C.'c CITY/zIP <br />CROSSSTREET APN fil�O - Q <br />PARCEL SIZE A4 41 LAND USE APPLICATION <br />OWNER NAME _ C7LJ�l� 1le, <br />tn711 <br />PHONE47/4 <br />OWNER ADDRESS�El / r�� <br />CITY/STATE/ZIP <br />/� <br />CONTRACTORPHONE.-) <br />•T <br />41-1-177-S <br />CONTRACTOR ADDRESS �ZS L <br />7 (T <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE .4CX-57 ❑ C-61 ❑ D - R9 ❑ Other NUMBER 3 7 X3M- EXPIRATION DATE_ <br />GEOGRAPHICAL INFORMATION: Coordinates : X Y <br />Township _ Range Section_ <br />INTENDED USE , <Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial <br />❑ Water Quality Monitoring D Soil Sampling/Characterization <br />❑ Public Water System <br />V different from Owner. Wmer <br />Sysm. .—Contact <br />Nme or P one um r <br />TYPE OF WORK `..New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Borin s <br />8() <br />M orborin ra El Geotechnical xorborinas <br />❑ Out -Of --Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />XrNew Pump ❑ Pump Replacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />Drilling Methotjjfg:Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool <br />❑ Push Point ❑ Other <br />Proposed Well Depth 4YW—ft Excavation in diameter <br />❑ Open Bottom .,1°Q'rave] Pack /Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -�C in Thickness/Gauge/ASTM Sched 3 W <br />❑ Steel 8CPIasfic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth �c' P ❑ Neat Cement (94 lb bag 15-10 gal water) <br />>RSand Cement_ a,� ,: • mix / 7 gal water <br />D Bentonite (20% solids) D Manufacturer Spec % solids _ % <br />_sack <br />Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method .]Stumped D Free Fall D Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Jf�Driller ❑Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length <br />ft Thick in ❑ Christy Box ❑ Stove Pipe <br />EMPE .0Zubmersible ❑ Turbine ❑ Other HP <br />Pump Set R Standing Water Level ft <br />nio Arr`Mn ASIvn AMU IHAI IHC] WUKK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />I MIN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNEDtq( {" TITLE VV,//Z'dj4- DATE <br />n <br />TMENT U. 11 'X0,4 LY <br />Application Accepted BDate O <br />Area Employee iD# <br />1:;?2" <br />Grout Inspection By <br />Dace " ice'/r7 _ <br />13SPECIAL Well Permit <br />Pump Inspection By te> <br />Date Qj/�G <br />❑ WAIVER Received <br />Constructed Well Depth <br />COMMENTS IQF��E/F Jj ACV <br />�� IJ /CS ��� <br />✓ r.r� c <br />PE SC Received Chec <br />Info B ash <br />Amount Date <br />Remitted <br />Permit/Codes <br />Service Re uest # Invoice # Well tD# <br />2 Q0 <br />G <br />Il17/2005� WELL PUMP PERMIT <br />