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i <br /> WELL 1 PUMP PERMIT <br /> SAN]DAQUmt COUNTY ENvtRQNWNTAL HEALTH DEPARTMENT 304 E WERER AvE 3P°FL-STOCKTON CA 95202- (209)46&3420 <br /> NON-REHNDA13LF PERMIT CALL 209 953-7697 FOR INSPECTIONS EXFIRES I YEAR FROM DATE ISSUED <br /> W.Z <br /> ADDRESS <br /> I� a CrrY/ZEP <br />' I'y <br /> CAW4 Q ARCEL SM---4—L—USE AerIAcATION# C <br /> �.. ROSS STREET +� <br /> Sg9 Sr�a'SCS�iI x *pyo b C lL: �1t PHONE ' <br /> OWNER ADDRESS 'I� `� W —` CrryiSTATEIZIP s l �- �f 1�! C+Y1��..7��O <br /> CONTRACTOR GI v PHONES of 2.S—/.3 �b 0 <br /> CONTRACTOR ADDRESS ClTb Y"e F'V _ CITYISTATEIz. I V{LA. 1 VVZ— <br /> SURCONTRACTOR . PHONE <br /> E <br /> SURCONTRACFORAODRESS <br /> LICENSE C-57 ❑C-61 ❑D-09 0 Other N R I A 1( <br /> GEo6RAPmCAL INFORMATION: Coordinates X Y Township—•Rao je Section <br /> i INTENDED USE 11 Domestic/Private ❑IrrigationtAgricultural 11Industri ty S erization , rr <br /> E <br /> 11 public Water S= I V <br /> k R dff-.t fmm Owaer' arer ystem arnc +f , V , ,� <br /> l d <br /> TYPE OF WORK El New Well Cl Replacement Well ❑Well Alteration/Mbr)>ifjcavot i I Ii T' °lo i Mat. <br /> s r 14 df t] �ate cal <br /> ❑Monitoring Well(s) #of wells 0 Soil Biring(s) <br /> ❑Well Destruction ❑Out-O€Service Well ❑Out-Of--Service Well Renewal <br /> ![ ❑New Pum ❑Pum lacement ❑Pum R air ❑Cross-Connection Repair <br /> WELL CONSTRUCTION �y <br /> grilling Method ❑Mud Rotary ec ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 10 Other F <br /> Proposed Weil Depth �—O p ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑ConducAtorICasing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter r&.r!4yn Thiclm S/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> sack mix 17 water <br /> Grout Seal Depth Sy"reG _ft eat Cemrnt(94 ib M915-10ga1 water) ❑Sand Cement Bm <br /> anufacturer Spec%solids—% Name ❑Specs on File ❑Spec Submitt <br /> Grout Placement Method mped ❑Other ❑Retardant/Accelerator(name) <br /> PEDVSTAL nstalled 0 Driller. ❑Pump Contractor ❑Other <br /> q' t4A% ❑Coorrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Boz 11 Stove Pipe <br /> I <br /> d PUW Ash ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft <br /> I T I ICATIO ORK L A 5 <br /> 7 UIN CO INAN TA LAWS, RULES APl GULATIONS. AL CER THA Q D Ll [ <br /> A CA ORNIA NTRACTORS ATE LICENSE B AND T[AM C L CE Wli L <br /> PE <br /> W MPE N <br /> !: M HOU I}VANCE N ICE REQUI IN ECTIONS <br /> SI :1. <br /> A D <br /> 1 <br /> EIVED <br /> 212004 <br /> - QUiN COUN'T'Y <br /> ONMENTAL <br /> DEPARTMENT <br /> .. rom �^ �IIMOElp r10.r EXPLM�l10�L9G��� <br /> ` .��.�i•�—nW ww �rt...wrir.resin nn m - 4eMr. ed1-. <br /> r - DCENT E ON -Y <br /> t �] � ul! <br /> Application Accepted By ate !�! Area -z�� Employee IDdk J / / 7 <br /> B Date T] SPE <br /> Well Permit <br /> Grout Inspectiony <br /> 1 PunvInspectionBy Date ❑ WAIVERReceived <br /> Destruction Inspection By Date Constructed Well Depth ft - <br /> + N <br /> fEt COMMENTS %1�� "_ <br /> PE SC Received eckkI Amount Permit/ IDvoicell Well mo <br /> Codes Info as <br /> Remitted ate Service Re nest# <br /> 3 <br /> wEu.PUMr t�na,uT <br /> k <br />