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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WFBER AVE 3"a FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> I 5 <br /> i1 S S (- Z -� <br /> JOB ADDRESS � 1 �0. � �• r CITYIZIP �` y <br /> CROSS STREET �w/ I V t�1M APN F ARCEL SIZE I Z© LAND USE APPLICATION# <br /> 7� rn <br /> OWNER NAME s+f�y��� hAt PHONE ��5 (:)?V <br /> y <br /> OWNER ADDRESS 3 r i �t CITYISTATE/ZIP TUGK 1���, --A <br /> �7 <br /> CONTRACTOR d_�-I O ti �A P O�l C! A Ss o L c PHONE Kl l -3(2 7` 3 <br /> CONTRACTOR ADDRESS 17 !VO 1..1-N W CITY/STATEIZIP L—,OO � C A= <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATTEEIIZIP ,✓� <br /> LICENSE C-57 ❑C-61 11D-09 ❑Other NUMBER vv EXPIRATION DATE 06 ! �ZQQ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section �- <br /> INTENDED USE ❑DomestiOPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization <br /> ❑Public Water System O <br /> If different from OWner: Water System Name c ame r In <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification I❑ th " <br /> ❑Monitoring Well(s) #ofwells ;Soii Boring(s) #I fir!{ii� may �o ,��� gtcrings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connects n Re air <br /> ❑New Pum ❑Pum Replacement Q Pum Repair Work being competed or inspected <br /> WELL CONSTRUCTION by k,.E~mronrn, .ia1 Health Division f` <br /> Drilling Method ❑Mud Rotary ❑Air Rotary *{61rg�r ❑Cable Tool ❑Push Point ❑Other <br /> ProposedPIdDepth 9—10 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> 6-kik,�S ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> I <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 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> MFB1 .,,. ..V 1 V PA T ON A WOR ON IN NC A <br /> IN ;OUNTY O INAN S, TE S, D RU SAN RE ULATIONS. IF H REQ t1C I <br /> rem- GNI ' ' CTI H LIF IA NT TORS STA SEB AN THA A IN L <br /> WORKS COMPENS IO WS.M U DV CE NOT] U !D R SPECTI SSIGNED TITLE COG/S�7 DATE � <br /> — flt7oo �riak _(llao)�ro�STA EETw� <br /> 9 11 ! 3 d 9 9 <br /> r v ;l N-- <br /> :ul <br /> 1 <br /> ,-,)- <br /> .,.slas '- t � v4" 6.F�wc <br /> -� 2 �s} <br /> T �T V <br /> � ^� a R L I -'9• 14 � I n x <br /> e � <br /> Ri 1L4 b n nr <br /> 0 N� L- <br /> WOR <br /> f� <br /> >? rr } l d 79 rr 1 3 b' 4 9 rr i <br /> � a <br /> i t - t• i7 1 99 F <br /> i r i • s <br /> DEPARTMENT USE ONLY V1 <br /> Application Accepted By�(A Zh <br /> Date Ci 13 Area Employee ID# �;q 4!_.__ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> I <br /> PE SC Received Check#! Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B �1 as Remitted Service Request# <br /> -FZ if �s S 0 <br /> V 3Er <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> 1127/2005 <br />