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WELL / PUMP PERMIT <br /> 304 E WEBER AVE 3Re FL-STOCItTON CA 95202 - (209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ; <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> NON.-REFUNDABLE PER C <br /> IT ALL 2091953-7697 FOR INSPECTIONS <br /> ✓� �,fir-� nJl �, <br /> �--�� � CrrY1ZIP <br /> JOB AD�DSc�T- <br /> g J 1 ASN ��q `D PARCEL SIZE LAND USE APPLICATION# <br /> CROSS STREET I�K T a <br /> FJ S rl�i Z�] CCI�G f�✓�. L L ` PHONE <br /> OWNERNAME r <br /> J/JJ /nom CITYISTATEIZIP C� 7 `�a j <br /> OWNER ADDRESS r o a <br /> �cL L PRONE <br /> CONTRACTOR <br /> ��! CITYISTATEIZIP fJut S�yO <br /> CONTRACTOR ADDRESS Z; `� 1111: YV <br /> G PHONE <br /> SUBCONTRACTOR ; ��'" r <br /> ,.f, g yi� <br /> y . CITYISTATEIZIP <br /> i SUBCONTRACTOR ADDRESS S1' Y�UC <br /> F NUMBER tfJ��7�r - EXPIRATION DATE <br /> LICENSE 1�9 C-57 ❑C-61 ❑D-09 ❑Other <br /> n y Township Range Section <br /> GEOGRAPHICAL INFORMATION: Coordinates X i' ri tion <br /> INTENDED SE ❑Domestic/Private ❑Irrigation/Agricultural (3 Industrial ❑ r�tta m g <br /> ❑Public Water System ger ystem &me ob t e or ofte um er <br /> If differem from Owner: i <br /> TYPE OF WORK ❑New Well ` ❑Replacement Well 17 Well AlterationlModification #of burin � 1 <br /> ❑Monitoring Well #of wells ❑Soil Borings) 1\1 <br /> ?( being �, <br /> ❑Out-Of-Service ❑Out-Of-Service Well Renewal Cross Connecti Repai;i Health D�lf is10n <br /> ❑New Pum !�❑Pum R lacement ❑Pum Repair <br /> viror' Q1t f, <br /> i WELL CONSTRUCTION ❑Push Point 14 Other t T <br /> Drilling Method ❑Mud Rotary ;p❑Air Rotary ❑Auger ❑Cable Tool <br /> Z in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> I Proposed Well Depth yf r 0� ft Excavation ft <br /> ❑Conductor Casihng � in diameter- 1 Conductor Casing Depth <br /> I ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Well Casing Diameter in ThicknesslGaugeIASTM Sched ❑Sand Cement sack mix 17 gal water <br /> Grout Seal Depth " R PDNeat Cement(94 lb bag/5-10 gal water) <br /> n ❑Specs on File ❑Specs Submitted <br /> /o <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids Name <br /> Grunt Placement Method ❑Pumped ❑Free Fall D Other <br /> ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By El Driller ❑Pump Contractor ❑ Other Thick ft C❑Christy Box ❑Stove Pipe <br /> 13 Concrete Pedestal Dimensions:Width ft Length in <br /> 1 NP Pump Set ft Standing Water Level ft <br /> PUMP ❑Submersible ❑Turbine 13 Other <br /> TIO A HE t• BE DONE IN A CORDANCE WITH SAN <br /> E g I H 'E PRE' RE T K. FY MA mi U N <br /> A IN COUN ORDI N STA' F LA ' AN ULES AN EGULATI AL <br /> T , Ll 'OR A CO RACTORS IGEN AR ND T AT All IN CO LI CE WIT LL <br /> WO RS COM SA N L <br /> j I HI LIR A] VANCE N RE I P R INSPE! I l( VS <br /> C TITLE DATE <br /> SIGNED L <br /> Vr <br /> .i <br /> iF <br /> N fR N E <br /> pM r <br /> - II DEPARTMENT U E ONLY 3 <br /> Application Accepted By _ <br /> ice---- Date s3 � � D� Area Employee ID# �5`� <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> Pump inspection By Date ❑ WAIVER Received <br /> 3! <br /> Constructed Well Depth :R ft <br /> COMMENTS (OLLr--c 4 7&0 .`'� � I`"t t&e-F_ tt66�rA,4 �f r��Vcd n►� [�►t/1T1� <br /> dh <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> i <br /> t <br /> WELL PUMP PERMIT <br /> EIiD 43-02006 <br /> 1/2712005 <br />