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WELL / PUMP PERMIT <br /> SAN JOAQUIN COu"Y ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFJJNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z 1 � i t)c'It (-13 CITY/ZIP S,�!/V G 1G i `'`& Cf 5-2-0-9- tM <br /> Ziff I / Q 7`'} O <br /> CROSS STREET f 1� ` ! lAPN '�� �50 PARCEL SIZE "' + LAND USE APPLICATION# <br /> OWNER NAMEV! �+ �PHOONE �^ <br /> OWNER ADDRESS f Zit �J T 4:r4 O'� CITYISTATEIZIP I U 9z I J <br /> CONTRACTOR 1jeL 0, � j��,'/ t3��f r /TSSOC/��/�� PHONE 3(0��.�0 <br /> CONTRACTOR ADDRESS fr/` 0ulS t 'L-1*L �� ! CITY/STATEIZIP <br /> SUBCONTRACTOR I! PHONE <br /> I� <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> y� <br /> LICENSE C-57 13C-61 Ij ❑D-09 ❑Other NUMBER �v EJCPIRATION DATE <br /> 1 6I 1 <br /> GEOGRAPHICAL INFORMATION: C061rdinatC3 X Y Township Range Section {v <br /> INTENDED USE ❑Domestic/Private` ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ; h <br /> � 1 <br /> ❑Pubiic Water System I <br /> If different from Owner: ate`System Name tact ame ne er v <br /> f TYPE OF WORK ❑New Well 73 Replacement Well ❑Weli Alteration/Modification 1 _ I ob&elr <br /> ❑Monitoring Well(s) #of wells Soil Borings) 1�PYMMay have, #ofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well RenewC <br /> ❑New Pum 13 Pum Replacement ❑Pum Repair 4orli agGmpl� Cor inspected <br /> 1 WELL CONSTRUCTION 11 y IRnvironma.�:tal Health Division <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ,Auger ❑Cable Tool ❑Push Point ❑Other <br /> iI <br /> t Proposed Well Depth 0 ft Excavation `D in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter 0 <br /> i 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> 1 <br /> ! <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 13 Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/S-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Sc7I L CU;f j6S ❑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 It Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> L...'[F HA PREP 'D Hll TION W E E A <br /> JO U COUNTY RDIN C TAT W AND LES AND GULATI0 SO ERTI T T V RE IR LICENS S <br /> AC A NI CON CTORS S NSE ARD 1 M MA <br /> OR 5 COMPS AT LA <br /> U 24 O R AD'S kNCE NO RE O INSPEC ORA q A <br /> SIGNED n TITLE F ew aj.66e DATE / T <br /> - - -- <br /> y # jW <br /> f s 4egoc <br /> Ar4 <br /> A — <br /> L-A fh <br /> �rAt <br /> pb <br /> P- ��27; <br /> U p Nm i l N <br /> ly <br /> _, II D E A R T.M E N T U7 O _L Y <br /> II - - -. _ <br /> Application Accepted By Date U Area Employee ID#� (� <br /> Grout Inspection B Date 11 SPECIAL Well Permit / <br /> p y <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth it <br /> COMMENTS <br /> n <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 7 A�' '0�9100 o� <br /> £HD 43-02-006 I� W ELL PUMP PERMIT <br /> 1127/2005 <br />