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S <br /> �. WELL! PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE Sap FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS i�J�/� + CITY/ZIP p <br /> CROSS STREET APN f ✓"^�1 ARCEL SIZE LAND USE APPLICATION# �y <br /> OWNER NAME PHONE <br /> 2&jcm <br /> OWNER ADDRESS <br /> CITYIS <br /> TATFIZSP --� <br /> � <br /> PHONE +� 321 <br /> CONTRACTOR t <br /> CONTRACTOR ADDRESS 4 CITY/STATE/ZIP <br /> SUBCONTRACTOR �� PHONE <br /> SUBCONTRACTOR ADDRESS <br /> ITYISTATEIZIP <br /> t LICENSE [3C 57 [3C-61 ❑D-09 ❑Other NUMBE EXPIRATION DATE <br /> I <br /> li y Township Range Section <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/.Characterization <br /> GINs <br /> Public Water System 1� <br /> If different from Owner: ater ystem arae ontact Bme or one um r <br /> it <br /> j TYPE OF WORK ❑New Well C Replacement Well ❑Well Alteration/Modification ❑Other <br /> FIRM❑Monitoring Well{s) #of wells ❑Soil Boring(s) # EnGe ech a��O`ut-Of-Service e 1 ❑Out-Of-Service Well Renewal io4 Kep <br /> C3 New Pump m Replacement ❑Plump Repair <br /> WELL CONSTRUCTION ve expired without <br /> i Drilling Method 13Mud Rotary :I[3Air Rotary 17 Auger ©Cable Tool wa , t (;Q m <br /> Proposed Well Depth 1. ft Excavation in diameter ❑Open (ErlV11roftuv l.PfdcdeRFI$�e�isio�.in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth �, ft G TURF I �J� <br /> -,Well Casing Diameter in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑.Other <br /> Grout Seal Depth 1 ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> i Grout Placement Method ❑Pumped 17 Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> r <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pi <br /> PUMP Submersible l3 Turbine 13 Other HP Pump Set ft Standing Water Level ft <br /> i PREP D TION E W DI,, <br /> E RD H <br /> J Q COUNT RDIN C TAT A AND LES AND EGULATIO LS CER Y UI D LICE, IS <br /> A HI CA CON CTORS ENS ARD ND T M COM LIA CE WITH L <br /> OR RS COMP A LA <br /> �7 2 O R AD NCE NO R F 1NSPEC0 <br /> SIGNED TITLE �.r� DATE <br /> Mj <br /> it 14. <br /> �j <br /> �j <br /> I� <br /> I <br /> i. <br /> �j <br /> j N - <br /> A 4 J A UI C U <br /> 11 IV 1R N E <br /> 'k <br /> 1 I <br /> `. <br /> M <br /> M <br /> I <br /> t <br /> k ! D PA TMENT. USIR ON YFF! <br /> T.Application-Accepted By Date Area I <br /> Grout Inspection By `i Date 11 SP A I t <br /> Pump Inspection By �p Date ❑ WAIVEIIt�Nil <br /> 2005 <br /> lE <br /> � Constructed Well Depth ft JlGr P <br /> EWARONMENT HEALTH <br /> COMMENTS <br /> PEWAITrSERVICES <br /> PE SC 1 Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Godes Info By Cash Remitted Service Request# <br /> � Sa II 3 � <br /> d <br /> 11 <br /> k ` <br /> EHD 43-02-006 I WELL PUMP PERMIT <br /> 1!27!2005 <br /> I� <br />