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WELL'I PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3"°FL-STpCKTON CA 95202 - (209)468-3424 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED a ' � ` JOB ADDRESS viN1 —NC , re_* °O`er CITYIZIP i CROSS STREET ilF u`C- APN nS-DTD 1,19 PARCEL SIZE LAND USE APPLICATION# OWNER NAME PHONE _�^+l � �`�// `-`��77 OWNER ADDRESS Q 0` �C�'1� �i��71 CITYISTATEIZIP S-00(YC 0zt Lk `�j 15 2- CONTRACTORC L •iF 1^t t��►`��N q �j�S T l PHONE ` CONTRACTOR ADDRESS Z. J]Lt&_ z7-+Ik CITY/STATE/ZIP I+V b 1 S Z+11 k SUBCONTRACTOR ,I PHONE SUBCONTRACTOR ADDRESS R CITY/STATE/ZIP ^' LICENSE -57 ❑C-61 ❑D-09 d Other NUMBER DQ EXPIRATION DATE GEOGRAPHICAL INFORMATION' Coordinates X Y Townsbip Range Section I INTENDED USE d Domestic/Private' ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ($oil Sampling/Characterization fv"? E)Public Water System If different from Owner: Water yslem arse Contact eine or one Num r TYPE OF WORK ❑New Well ❑Replacement Well d Well Alteration/Modi6b n ❑Monitoring Well(s} #Of wells Soil BOrin g(s) catio ft c eot al ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair L ❑New Pump 0 Pump Replacement ❑Pump R I�air f ermit m� gave expired without F WELLCONSTRUCIION IT workbeing comsleted or inspected Drilling Method d Mud Rotary ©Air Rotary Auger d Cable Tool ❑.Push Point�p t e i Proposed Well Depth 10 1- ft Excavation� in diameter 13Opcottrr oftogvi ronrh�ba Pve e� in diameter [3 Conductor Casing in diameter / in Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched d Steel d Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft 0 Neat Cement(94 lb bag 1 5-10 gal waler) ❑Sand Cement sack mix l7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name S131 S ❑Specs on File d Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑'Driller ❑Pump Contractor ND Ther ❑Concrete Pedestal Dimensions:Width ft r Llength ft Thick in d Christy Box ❑Stove Pipe PUMP ❑Submersible ❑,Turbine ❑Other Pump Set ft Standing Water Level ft a . ,Rl cnilF ■ PREP D 11, (TION T E W E -- BOAC I JO COUNTY )I IN C TA W AND LES AND GIILATI0 S ERTI T Y RE( TIP D LICENS S AC H A N CON CT S ENSE ARD T I M cOM° _lAl D L 11 WOR S COMPS ATI LA N 24 O NCE NO RE INSPEC or � r y �G SIGNED TITLE �+ t', / DATE `` � M�,Poo 175-04 °'I°. 3 — „ _�--— °OELL © VI51x —'_ LVE© __�s$ c I` LOT U -1 I �� QQ ,b L' MOSSWOOD PARK 4 LtTr SOALE,Imo°-104D II \ 8AN JOAOUtttii QOUN" C OSSE950Rg MAPS A_R T:M=E N Tr.-U SE O'N_L Date Area Employee lD# i Application Accepted BC 4d Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Constructed Well Depth ft f COMMENTS .. JA 1 i. PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info BY Cash Remitted Service Request# 00 X5 s WELL PUMP PERMIT EHD 43-02-006 - _ - 1127I2t1O5 I� 1.