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_ WELL I PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT Ii CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 01 P <br /> JOB ADDRESS 1241 `—t 1° 1'. � J CITYIZIP � Co !v > <br /> CROSS STREET O I� d APN IIO3-370-Z`F._.r�PARCEL SIZE_LX LAND USE APPLICATION# <br /> OWNER NAME jee.4j {ID. PHONE <br /> IIr{ OWNER ADDRESS 0(oIO N CITY/STATE/ZlP �2 1 Z <br /> r CONTRACTOR IJ61L O. .I" C G PHONE ?Z17-347-37--of <br /> CONTRACTOR ADDRESS %0Z 11JA)0t1S7g1& tA)Ay CITYISTATE/ZIP 6VQi� Cd <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS IM CITY/STATEIZIP <br /> IO <br /> LICENSE VC-57 ❑C-61 ❑D-09 ❑ (OOther NUMBER O ExPiRATION DATE <br /> I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> 1f difTerem ffom Owner: ater ystem Name e" n I Ie el L-A L- r <br /> I <br /> 1 il-j <br /> TYPE OF WORK ❑New Well -Ik❑Replacement Well ❑Well Alteration/Modification .13he}u <br /> ofborings a of borings rings <br /> I I I EP,- <br /> E3 Monitoring Wel S) #of wells oil Borng(s} <br /> )( C U �l�t 0"COYlhou} <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ross- ntii <br /> ❑New Pum !(0 Pum Replacement ❑Pum Repair work being c ir <br /> WELL CONSTRUCTION bx [+c,virorm. al Health DkIsion <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Push Point 0 Other <br /> Proposed Well Depth 10 !S ft Excavation I► in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth (7 - 1'S ft I(Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%�solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By O'Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> 4 <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I PREP D H TION T E W K E D H <br /> J COUNT RDIN C TAT AND LES AND GULAT10 LS ERT A Y R I D L[CENS 15 <br /> A H� CA RN CON CTORSS ENS ARD D T I M I H L <br /> OR COMPE A LA <br /> `i 2 O RAD NCE N R INSPEC O <br /> SIGNED IM TITLE 7 FE 5uc,Lkln5e DATE <br /> I� <br /> JA <br /> - Navy i)rt levy Dr v <br /> F St <br /> f VV <br /> t <br /> �• ° � � l �, �� °i ��413'".w1^-'4 �-a r�" �¢ri�`���'i�S— s " q�h9 �`i : "• ..: � <br /> �- <br /> zV <br /> ri, € � I`` t►�1tn1 � '�11U��3 Ep! ' � 3 � <br /> ja <br /> w <br /> IM E 1 <br /> ..R T-M-E`N T-U S E O-N L-1r <br /> Application Accepted B \l4YUV� L <br /> ` Date 3 Area Employee ID# <br /> Grout Inspection By I Date ❑ SPECIAL Well Permit <br /> k Pump Inspection By �II Date ❑ WAIVER Received <br /> E Constructed Well Depth II ft <br /> COMMENTS ������ �fll,✓i+IFTr � - - <br /> J: <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> F EHD 43-02-006 WELL PUMP PERMIT <br /> 1t27t2005 <br />