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WELL / PUMP PER1Y[LT oqgo <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-RFBIINIIARIX.. PRDUTT !'Ar I IIAMA., e1n1. .. <br />//// r(7 - -- --- - •-•....... - ui�� iau'�v ,iv/! Gn!! r'e1U111 LA 161.�7ULL <br />JOB ADDRESSy 3S / �.CITY/ZIP <br />`r <br />CROSS STREET () 1 APN �' O D PARCEL SIZE Ak 0/ LAND USE APPLICATION # <br />OWNER NAME t.._VC /�tSt�L�, �/t, YLi.H PHONE`j ID <br />OWNER ADDRESS�I� / r ► �� CITY/STATFJZIP <br />CONTRACTOR A a -A Ggag66 <br />� f /�Y PHONE 33 y 4/7 ZS <br />CONTRACTOR ADDRESS po 3T/ [ 7(Y CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CrrY/STATE/ZtP _ <br />LICENSE >41:-57 ❑ C-61 ❑ D-$9 ❑ Other NUMBER 12-m EXPIRATION DATE_ <br />GEOGRAPHICAL INFORMATION: Coordinates : X Y Township _ Range Section <br />INTENDED USE ,y�_113omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System _ <br />UdiD2rent from Owner: ater ystem emeContact Name or one um r <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # ofwells ❑ Soil Borings) µOf bOf1"x' ❑ Geotechnical a of bo ngs <br />❑ Out -Of -Service Well ❑ Out -Of --Service Well Renewal ❑ Cross -Connection Repair <br />-ICENew Pump ❑ Pump Replacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />Drilling Metho,l,-*EU4ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth9_92Excavation in diameter ❑ Open Bottom ' ('travel Pack / Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel A'Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ge,-Aa ft ❑ Neat Cement (94 lb bag/5-/0 gat water) Sand Cement_fr sack mix / 7 gal water <br />E3 Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method bumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDE AL Installed By Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove 57771 <br />PUMP JBSubmersible ❑ Turbine ❑ Other HP _ Pump Set ft Standing Water Level ft <br />-, a.Gnurr Inn, , r,nve, retcrnRru I.V1 ArrLICAIIUN AND THAT THE WORK 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MIN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 9-7-(3( <br />/{� S r-�p <br />SIGNED �JL_ TITLE Vk//I'Gi, DATE V ` / ``" <br />O <br />yl\ <br />I1 <br />14 <br />P RTMENT U E O LY _ <br />1 f <br />Application Accepted B Date Area Employee ID# <br />Grout inspection By Date —�/nr ❑ SPECIAL Well Permit <br />Pump Inspection By Date �//riC ❑ WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS a D t tW- <br />PE SC <br />Codes Info <br />Received Check# <br />B ash <br />Amount <br />Remitted Date <br />Permitl <br />Service Request # Invoice # Well ID# <br />Qti <br />EHD 43-02.106 <br />112W2005WELL PUMP PERMIT <br />