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WELL 1 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 I� CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Jon ADDRESS 1Y, q,71 C- J i <br /> I o <br /> CROSS STREET i p Nye S APN 'U!�C> '_�� PARCELS E S PP 1 <br /> OWNER NAMEC.- <br /> II im��ve ex,�[� c� wit <br /> ireh .._-- <br /> out <br /> OWNERADDRESS CITVwwk* Lc ( (1171UIP.tP.d Oi IrlS�CfOd ' <br /> CONTRACTOR 1,31F—k 011 <br /> li),f- Sang _Ns.&c> --\ Health Division <br /> CONTRACTOR ADDRESS �Z I� �Q iI�> `^� \ I� \(`1 CiTVISTATE/ZIP Lt3 O1 L 0 S Z�k b <br /> SUBCONTRACTOR I�. PHONE <br /> `I I <br /> SUBCONTRACTOR ADDRESS IM CITY/STATE/ZIP <br /> LICENSE 1 F%C-57 ❑C-61 1'l.11 D-09 ❑Other NUMBER—nn�-ODS EXPIRATION DATE_ 0-7 <br /> I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section , <br /> INTENDED USE ❑Domestic/Private I` ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring IKSoil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Comael Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑MonitoringWelk s} #of wells ❑Soil Boring(s)s 0 of boringsZ- <br /> 13 <br /> p of twrings <br /> ( g{ ) �(',eotechnical Z <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pum Repair <br /> WELL CONSTRUCTION I� <br /> Drilling Method ❑Mud Rotary ❑,hAir Rotary �9 Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth jS 1It Excavation�_in diameter ❑Open Bottom 13 Gravel Pack/Gravel Size in diameter N <br /> ❑Conductor Casing II in diameter 1 Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water f(� <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 13 Pumped [A.Free Fall ❑Other ❑Retardant/Accelerator(name)*AQI Y 'CL--k -X r tz.,W I <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ .� p <br /> ❑Concrete Pedestal Dimensions:Width ft 1`JL th ft Thick in 11 Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP ry Pump Set fl Standing Water Level ft 1 <br /> V PA T _.__lON A T WO W N IN NEAL <br /> JOA( TIN "OUNUYO DINAN 5; TE S, D R ES AND R ULATIONS. O T1PY H REQU C ;N- AAlii A�- I' c HLI IA ONT 'TORSSTA SEB DAN A IN N <br /> R COMPENS WS <br /> h <br /> 1 H U DV CE NOT �1U ED _lR SPECTI,�J N <br /> SIGNED TITLE <br /> - STv4F IrP.Lat-I 7'1 r—E t L—DATE <br /> Fin <br /> FA <br /> 5 <br /> _ �t�l n74 5AR'KNtH . <br /> t t <br /> rlma�n u�W <br /> �R{i�SlArt kR.13 � a -[ <br /> P- <br /> r <br /> Nato 1N <br /> t ? b1V R R <br /> iviet <br /> I' <br /> .DE.PA-RTMEN-T`U'SE ONL-Y---_ <br /> Application Accepted By Date �( Area Employee ID# <br /> Grout Inspection By I`M Date 11SPECIAL Well Permit <br /> Pump Inspection By. I`l. Date 13WAIVER Received <br /> Constructed Well Depth II ft l <br /> I <br /> COMMENTS IN <br /> JI <br /> H4:F '# I <br /> �I <br /> PE SC Received II C eck#► Amount Date Permit! Invoice# Well ID# <br /> Codes Info B I ash emitted Service Request# <br /> 'f3.7 L50 I(,-;LD sdzo.dV t rII SROOLAS3 <br /> I� <br /> I� <br /> EHD 43-02-006 - WELL PUMP PERMIT <br /> 1/27/2005 <br /> — w # <br />