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k <br /> a WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3u'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS Y/ 270 L 5"(— <br /> J ( 6/ClL- JV' ^V ... TSL.+C V <br /> 1 / 4a D CITYIZ[P Y <br /> CROSS STREET APN 5- 9f/ *7 X <br /> ryCiLi•,] � PARCEL SIZE 7/i / LgNpUSE APPLICATION# � <br /> OWNER NAME IJ V 1�� Bid/ PHONE 15 <br /> OWNER ADDRESS ITYISTATEIZFP <br /> CONTRACTORP �ON�E/fd7 3'iJ ,/�j"o� <br /> CONTRACTOR ADDRESS �:� W�N %y CITYISTATEfZIP p L�µ.i�'��` `C�/� c? ?(�S <br /> I <br /> SUBCONTRACTOR PHONE <br /> w <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE. C-57 ❑C-61 al❑D-09 ❑Other NUMBER,;�65-S-S-6 r EXPIRATION DATE <br /> It <br /> GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section <br /> INTENDED USE mesticlPrivate ❑Irrigation/Agricultural 0 Industrial 1�ate 1'{`y �' g Y amplirWX racterization <br /> ❑Public Water System <br /> If different from owner: Water System Name o act Pb&ge u r I L <br /> TYPE OF WORK *W Well ❑Replacement Well ❑Well Alteration/Modification Pe I NI!!✓smoy haE, (?3)ep rl tnrithni rf <br /> H o bo Ings, `N of borings <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) t, t�htt �I <br /> �vorC dein cam[ [CJJ <br /> ❑Well Destruction 13 Out Well Q Oqt- Service VJeJ l�enewa <br /> ew Pum ❑Pum Replacement ❑Pum Repair by ❑1&[rzE.T6ecti.,ai - of ,t <br /> WELL CONSTRUCTION I` <br /> Drilling Method ❑Mud Rotary `)k4ir Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth!ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size an diameter <br /> ❑Conductor Casing' in diameter I Conductor Casing Depth ft cc�yll <br /> Well Casing Diameter in is Thickness/GaugeIASTM Sched .f-D&0 ❑Steel ,plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft )eat Cement(94 Ih 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 /> Grout Placement Method 3pumped ❑Free Fall ❑Other ❑Retardant!Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor k6ther ✓nl�t�- <br /> Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> Pump X.Submersibie (3 Turbine ❑Other HP Pump Set ft Standing Water level a.� ft � <br /> RE Y AV REPA T 5 ION A Volr <br /> O I AN S <br /> 1 ES ATE S, N AND R E E <br /> CU AND ACT E ALI 1 ONT CTORS ST E LICENI OMP N WITH A <br /> E AW <br /> CE NOT ERE T IN'.SIGNED TITLE 'rDATE <br /> 4 F f _ T �5ti8'S4'34"Ec,F� gEC.E4 SEC.�Is <br /> 651.11 % BEC.9 SEC.2 <br /> .� —SET POINT <br /> ON LINE <br /> (TYPICAL) <br /> LS <br /> a � o <br /> m , <br /> l r �- <br /> "' <br /> F <br /> /,BULL N I <br /> Cn �i <br /> jeebLN <br /> y°tPN z�3-Z3o-rs [} PRT E T <br /> IN <br /> J o� <br /> t 3 e- SGs4�E ! •= Noo <br /> 73.07' S� <br /> �111(79RAjli N89'25'53"E su5� L <br /> �1 W,t W 0R q�R <br /> J KIPa c .r I <br /> "`' = <br /> Application Accepted By Date Area Employee I D# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received iheck#/~ Amount Date Permit/ Invoice# Well III Info B Remitted Service Request# <br /> 7 CL3 �d 0 4-003Gi <br /> EHD43-02-006 li WELL PUMP PERMIT <br /> K6/04 I <br />