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u <br /> WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953J697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> v CITYIZIP"5 z a <br /> v <br /> c� v <br /> CROSS STREET Y` PN Q t -"t qO " PARCEL SIZE O' LAND USE APPLICATION# y <br />' OWNER NAME A Af <br /> r6d7 L,1 } �° PHONE <br /> 46 - 06o y <br /> OWNER ADDRESS c) "V ` C CITYISTATE/ZIP 5TO r. <br /> CONTRACTOR PHONE <br /> a CONTRACTOR ADDRESS CITY/Sf))PH <br /> SUBCONTRACTOR <br /> H NE L y <br /> i Pig <br /> SUBCONTRACTOR ma hale exeired wFthaut <br /> SUBCONTRACCORADDRms CITYISTAT ZIp <br /> LICENSE 0C-57 0C-61 ,I 13 D-09 ❑Other NUMBER Work hgtC 't 'fed or inspected <br /> E.-yjrorw_ ,� ealth W"ion <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y owns Ip <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> a <br /> ❑Public <br /> I <br /> WaS <br /> Contact Name or ane Number <br /> rent mIfdireefirm Water System Name <br /> TYPE OF WORK O New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> p of borings ❑Geotechnical 4 of borings <br /> ❑Monitoring Well{s) #of wells ❑Soil Boring(s) <br /> XOut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> E3 New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> k <br /> Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool ❑Push Paint ❑Other <br /> Proposed Well Depth .1l ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> CAj <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft Q <br /> Well Casing Diameter in, Thickness/Gauge/ASTM Sched. ❑Steel ❑Plastic ❑Stainless Steel ❑Other W <br /> h <br /> Grout Seal Depth II ft ❑Neat Cement(94 lb bag l5-10gat 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 ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) C <br /> M <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other 1y. <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Steve Pipe +1 <br /> i <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft n <br /> ...'IFl <br /> ..11111111kHA PREP :D ' HI's 'ON TION E W E A <br /> JO COUNTY RDIN C TA ►Wt AND LES AND GULATlO SO ERTI T T Y RE I LICENS S <br /> CO <br /> - AC A RNI CON CTORS S ENSE RD D T I M IA L <br /> OR �E AT LA <br /> U 24 IOl Z AD NCE NO E O 1N EC O <br /> SIGNED 1 TITLE A DATE <br /> a <br /> LS <br /> I <br /> I <br /> aF <br /> I <br /> lig <br /> �1Y <br /> I' F A S A TA <br /> 1 <br /> D,E PART M E N T_- SE ONLY <br /> _ <br /> Application Accepted By I -� Date Q5 Area Employee]D# <br /> Grout inspection By Date ❑ SPECIAL Weli Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS D IGT• f) 1E 0• Cit tJr 2 � �e+r t [ yC�DS C .�t F—_ <br /> to A.) <br /> PE SC Received Chec Amount per itj <br /> DateInvoice# Well ID# <br /> Codes Info By Cash Remitted ce R uest# <br /> q3 -z ZI73 loo.00 <br /> i <br /> t <br /> EHD 43-02-W .4 WELL PUMP PERMIT <br /> 1/27/2005 <br />